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Health Assessment- Medicare Health Risk Assessment

Confidential Health Assessment

The following information will be held confidential and will help us assess and accommodate your individual healthcare needs.

Note: If you prefer to complete the assessment over the phone with a Case Manager, or if you have questions, please call us at 1.866.334.3141 (TTY:711).

We are available October 1 - March 31, 7 AM – 8 PM, seven days a week (excluding major holidays) and April 1 - September 30, 7 AM - 8 PM, Monday - Friday (excluding major holidays).

Your Personal Information

Name *This question is required.

Today's Date *This question is required.

Medicare ID: *This question is required.

Address:

City, State, Zip:

Date of Birth: *This question is required.

Home Phone: This question requires a valid number format.

Mobile Phone: This question requires a valid number format.

Please specify the individual completing this form

Do you have a medical power of attorney for medical care? If so, please list their name(s) and number(s) here.

As part of preventive medicine, we encourage our members to complete advance directives. Advance directives allow individuals to voice their treatment preferences and goals of care in the event of a serious illness or accident where they are not able to communicate their wishes. Do you have any the following advance directives?

Would you like information on completing advance directives?

An alternative would be to consider visiting MyDirectives.com to access resources to complete a digital directive online.

Which one physician do you identify as your Primary Care Physician (PCP)?

PCP/Clinic Name: