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HEALTH SCREENING FORM & RESULTS
As part of the CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. Blue Rewards program,
you are eligible to receive a health screening.
This form can be used for an annual biometric health screening at any CVS MinuteClinic.
PRINT NAME: DATE:
PROVIDER: See processing instructions below.
VOUCHER
what you should know before your visit:
• This printed form along with valid photo identification and CareFirst insurance
card
are r
equired at time of visit.
• Biometric health screenings are available every day.
Online appointments required
at select locations. To find a MinuteClinic, please visi
t minuteclinic.com or call
1.866.389.ASAP (2727).
•
After registering at the kiosk, patients will be pre-screened and required to wait
outside the store until called in for visit.
• For best results, we recommend that you fast 8 to 12 hours before your visit.
• Patients 18 years of age and older are eligible for a biometric health screening.
• This screening shouldn't replace an annual wellness physical with your provider.
• This form can only be used at MinuteClinic and not CVS Pharmacy.
MinuteClinic Provider Instructions
• Ask customer to provide photo identication
• Ask customer to print name and date on the biometric health screening
voucher in the designated area
• Match customer’s identication with the name written on voucher
• Collect and input customer’s insurance information into the EMR
• Select biometric health screening as the chief complaint
It is mandatory to collect all of the following information
and input all results into EPIC/EMR as well as
documenting the results within the below ÿelds.
After the screening results have been clearly written
in the ÿelds below, detach the screening results section
and give it to the patient.
screening results
indicates required ÿelds
Smoking/Tobacco
Blood
BMI
Use?
Pressure
Smoker
Blood
Glucose
Height
Non-Smoker
in inches
Reading
Flu Vaccine
Fasting?
Yes
No
Within the Last
Weight
in pounds
12 Months?
Total
Cholesterol
Yes
Waist
Measurement
No
in inches
A1C
submitting results
Submit the results of this completed health screening form by logging in to your account at www.carefirst.com/sharecare and navigating to
"Achieve". Next, select "Rewards", then "Blue Rewards Incentive Program". Select "Complete a Health Screening" and "Enter Your Results".
IMPORTANT NOTES:
MinuteClinic will not accept offers printed from unauthorized internet postings or reproductions, copies or facsimiles of this voucher/offer. Age restrictions for biometric
health screenings may apply. Original biometric health screening voucher must be surrendered at time of the screening. Biometric health screening voucher offer is void
where prohibited by law. Limit one voucher per customer. No cash back.
CVS MinuteClinic is an independent company that provides medical services to CareFirst members. CVS MinuteClinic does not provide CareFirst BlueCross BlueShield products or services and is solely responsible for the medical
services it provides. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical
Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the
business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.).
BLUE CROSS
®
, BLUE SHIELD
®
and the Cross and Shield Symbols are registered
service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
