© 2019 YMCA Employee Benefits

ACCESSING YOUR HEALTH PROVIDER SCREENING FORM

YMCA Employee BenefitsWellnessWorks Program

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ACCESSING YOUR HEALTH PROVIDER SCREENING FORMSTEP 1: To download the Health Provider Screening Form, you’ll need to log in to myuhc.com and click on the Rally Health & Wellness link. If you haven’t already taken your Rally Health Survey for the year, you’ll be prompted to do that first.

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STEP 2: Once on your Rally Dashboard, click on the Rewards tab and locate the “Complete a Biometric Screening” Incentive, then click Learn More to continue on to Quest Diagnostics and register for your screening

ACCESSING YOUR HEALTH PROVIDER SCREENING FORM

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STEP 3: On your Quest Diagnostics dashboard, select Schedule an Appointment to access your form.

PLEASE NOTE you won’t actually be scheduling any appointments here. That language is referring to employers who offer on-site biometric screenings to their employees. You’ll need to click “Schedule an Appointment” to download

the form and then contact your primary care physician separately to schedule an appointment.

ACCESSING YOUR HEALTH PROVIDER SCREENING FORM

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STEP 4: Next, you’ll return to your dashboard and now see the option to Order Form underneath the Wellness Screening section

ACCESSING YOUR HEALTH PROVIDER SCREENING FORM

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STEP 5: You’ll receive a confirmation message that your form is ready to be downloaded. Click Download Form to get a printable PDF attestation form that you’ll need to have filled out by your physician.

ACCESSING YOUR HEALTH PROVIDER SCREENING FORM

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NEXT STEPSPrint out a copy of your form and schedule an appointment for a preventive exam or biometric screening with your Primary Care Physician. If there are tests listed on the form that your physician does not think are preventive based on your age and/or health history, they may put “N/A” on the form.

Ask your doctor to complete the form once your test results have been received and choose one of three options for returning the form for processing.

To submit your form, you can:1. Ask your physician to fax the completed form to the

confidential number provided on the document

2. If your doctor is unable to fax the form, ask that it be filled out and returned to you so you may fax it yourself

3. Upload a digital copy to the Quest Diagnostics site and submit electronically

REGARDLESS of which return method you use, make sure that the form is completed and signed by both you and your doctor

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DON’T FORGETMake sure your email address is correct and legible on the form—this is how you’ll be notified if there was an error on your form, as well as when your gift card is ready.

The WellnessWorks incentive year starts over again every August 1. To qualify for the current year’s reward, the form must be submitted before July 31.

Make sure both you and your doctor sign the form. Check that all information is filled in and accurate before submitting.

The information you submit on the form is confidential and will not be shared with anyone at your YMCA or at YMCA Employee Benefits. The confidential fax number goes directly to UnitedHealthcare, where they’ll process the form and use the information to update your Personal Health Record on myuhc.com.