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WELLNESS EXAM COMPLETION FORM City of Rexburg 35 North 1st East Rexburg, ID 83440 www.rexburg.org Phone: 208.359.3020 Fax: 208.359.3022 Each of the following listed services qualifies under Blue Cross
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How to fill out wellness exam completion form
How to fill out a wellness exam completion form:
01
Begin by carefully reading through the entire form to understand the information required and the sections you need to fill out.
02
Start by providing your personal details such as your name, date of birth, contact information, and any other pertinent identification information as requested.
03
Next, provide information about your primary healthcare provider, including their name, contact information, and any relevant identification details.
04
Fill in the date of your wellness exam. This is typically the day you visited your healthcare provider for the exam.
05
If requested, provide information about your insurance coverage. This may include your insurance provider's name, policy number, and any other relevant information.
06
Complete any sections related to your medical history, including any existing or past conditions, medications you are taking, allergies, and vaccinations.
07
In the next section, provide details about your wellness exam. This may include information about your weight, blood pressure, cholesterol levels, and any other measurements taken during the exam.
08
If there is a section for additional notes or comments, you can use this space to provide any additional information relevant to your wellness exam or your overall health.
09
Review the form once completed to ensure all the necessary sections are filled out accurately.
10
Finally, sign and date the form, indicating that the information provided is true and accurate to the best of your knowledge.
Who needs a wellness exam completion form?
01
Individuals who have recently visited their healthcare provider for a wellness exam.
02
Patients who are required to provide documentation of their wellness exam completion as part of their employment, school, or insurance requirements.
03
Anyone who wants to keep track of their personal health information and have a comprehensive record of their wellness exam.
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