Physician/Advanced Practice Clinician (APC)
Screening Form Overview
Healthy Living 2024
Skip an on-site screening and submit a Physician/APC Screening Form as one of the options to
complete a Healthy Living Screening.
• Participants must each complete the Health Questionnaire and sign the Screening Consent Form on their
own Healthy Living Portal before uploading the form. Forms will not be reviewed by the Healthy
Living team if the Screening Consent Form is incomplete.
• This form cannot be used in place of a Retest Screening or Follow-Up Screening. Participants in the
Preferred and Select Medical Plans must schedule these screenings on their Healthy Living Portal. Out-of-
Area Medical Plan participants should call the Healthy Living Solution Center at 800-937-5717.
To take advantage of this Physician/APC Screening Form option, complete the following steps:
STEP 1: Have your physician/APC complete the entire Physician/APC Screening Form. (See page 3)
• Height and weight measured within the last 6 months.
Note: If you choose the Physician/APC Screening Form, your body fat percentage measurement will not be
taken and will be excluded from your 2024 Healthy Living Screening. Only your BMI (calculated from your
height and weight) will be used to determine if you have a BMI risk.
STEP 2: Upload the completed Physician/APC Screening Form to your own Healthy Living Portal.
• Log in and scroll down to the ‘Document Upload Center’ box. Click on the box and choose
Physician/APC Screening Form.
• Select ‘browse’ to find the document (completed form) on your computer, then click the ‘upload’
button.
• You will receive an email within 10 business days notifying you whether your form has been approved or
denied.
Deadline to upload your completed form is June 22, 2024, to be eligible for the full $500 reward.
Forms received after this deadline but before Nov. 1, 2024, will only be eligible for the $100 reward tied to
completion of the Health Questionnaire and a screening.
NEXT STEPS
Once your Physician/APC Screening Form is approved, the $100 portion of your Healthy Living Reward will
be added to your paycheck within two pay periods.
Complete the next steps to earn your full reward – see page 2.
Questions? Contact the Healthy Living Solution Center at 800-937-5717, 8 a.m. – 6 p.m. CT, M-F.
AAH Benefits | 12.2023
Physician/Advanced Practice Clinician (APC)
Screening Form Overview
Healthy Living 2024
NEXT STEPS - continued
*Completing a Healthy Living Support Program and/or the Follow-Up Screening will determine the amount
participants earn towards the full $500 reward. If your BMI is ≥ 30 and you choose not to complete a
support program, you can still earn the $150 portion by successfully completing a Follow-Up Screening! You
will be rewarded the applicable dollar amount within two pay periods for each activity you complete.
**If you think you might be unable to meet a standard for a reward under the Healthy Living Program, you
might qualify for an opportunity to earn the same reward by different means, including waiver. Contact the
Healthy Living Solution Center at 800-937-5717 and we will work with you (and, if you wish, with your
health care provider) to find a reasonable alternative program with the same reward that is right for you in
light of your health status.
Questions? Contact the Healthy Living Solution Center at 800-937-5717, 8 a.m. – 6 p.m. CT, M-F.
AAH Benefits | 11.28.2022
AAH Benefits | 12.2023
Physician/Advanced Practice Clinician (APC)
Screening Form
Healthy Living 2024
Have your physician/APC enter your height and weight measured within the past 6 months in the space
below. This form must be completed in its entirety and uploaded to the Physician/APC Screening
Form inbox in the Document Upload Center on your Healthy Living Portal by 11 p.m. CT on June 22,
2024, to be eligible to earn the full $500 Healthy Living Reward. Forms received after the June 22
deadline but by 11 p.m. CT Nov. 1, 2024, will only be eligible for the $100 reward tied to completion of the
Health Questionnaire and a screening. By signing below, you acknowledge that you understand that once this
form is submitted, these will be your Healthy Living Screening results for the 2024 program.
/ / M F
Participant Name (please print) Date of Birth Gender (circle one)
Participant Signature
Address City State Zip Code
Teammate Spouse/Partner
Phone Number Participant ID Circle One
TEST YOUR RESULTS
Height _______ ft _______ in
Weight ___________ lbs.
/ /
Physician/APC Name Date of Service
Physician/APC Signature NPI Number - Required
Address City State Zip Code
Phone Number
AAH Benefits | 12.2023
