Section 4 To be completed by your primary care provider – Primary care providers should fill out this form for Healthy Michigan Plan beneficiaries enrolled in Managed Care Plans only. Fill in the Member Results, select a Healthy Behavior statement in discussion with the member, and sign the Primary Care Provider Attestation. Blood pressure, BMI and tobacco use status will be known from the appointment. For all other Member Results, marking the result as unknown and indicating whether the screening or immunization is recommended satisfies the requirements for a complete Health Risk Assessment. All three parts of Section 4 must be filled in for the attestation to be considered complete. Member Results Blood Pressure (xxx/xxx mmHg) Yes No Patient diagnosed with hypertension? BMI Ht Wt. In the context of all relevant clinical factors, does this BMI indicate Yes No need for weight management? BMI (xx.x) Tobacco Use Status Never used tobacco Previous tobacco user Current tobacco cessation Starting tobacco cessation Tobacco user Cholesterol Yes No Yes No Cholesterol known? Patient diagnosed with high cholesterol? If cholesterol known is Yes: Total cholesterol: LDL: Date of most recent test results: HDL: Triglycerides: If cholesterol known is No: Screening not recommended Screening Ordered Blood Sugar Yes No Yes No Blood sugar known? Patient diagnosed with diabetes? If blood sugar known is Yes: FBS (xxx mg/dl): Date of most recent test results: A1C (xx.x%): If blood sugar known is No: Screening not recommended Screening Ordered Influenza Vaccine Yes No Annual Influenza Vaccination? If Influenza vaccination is Yes: Date of most recent vaccination: If Influenza vaccination is No: Vaccination not recommended Vaccination recommended First Name, Middle Name, Last Name, and Suffix mihealth Card Number Healthy Behaviors - 4) Choose one of the following statements (1 - 1. Patient does not have health risk behaviors that need to be addressed at this time.
Section 4 – To be completed by your primary care provider Primary care providers should fill out this form for Healthy Michigan Plan beneficiaries enrolled in Managed Care Plans only. Fill in the Member Results, select a Healthy Behavior statement in discussion with the member, and sign the Primary Care Provider Attestation. Blood pressure, BMI and tobacco use status will be known from the appointment. For all other Member Results, marking the result as unknown and indicating whether the screening or immunization is recommended satisfies the requirements for a complete Health Risk Assessment. All three parts of Section 4 must be filled in for the attestation to be considered complete. Member Results Blood Pressure (xxx/xxx mmHg) Patient diagnosed with hypertension? Yes No BMI Ht Wt. BMI (xx.x) In the context of all relevant clinical factors, does this BMI indicate need for weight management? Yes No Tobacco Use Status Never used tobacco Previous tobacco user Current tobacco cessation Starting tobacco cessation Tobacco user Cholesterol Cholesterol known? Yes No Patient diagnosed with high cholesterol? Yes No If cholesterol known is Yes: Total cholesterol: LDL: Date of most recent test results: HDL: Triglycerides: If cholesterol known is No: Screening not recommended Screening Ordered Blood Sugar Blood sugar known? Yes No Patient diagnosed with diabetes? Yes No If blood sugar known is Yes: FBS (xxx mg/dl): Date of most recent test results: A1C (xx.x%): If blood sugar known is No: Screening not recommended Screening Ordered Influenza Vaccine Annual Influenza Vaccination? Yes No If Influenza vaccination is Yes: Date of most recent vaccination: If Influenza vaccination is No: Vaccination not recommended Vaccination recommended First Name, Middle Name, Last Name, and Suffix mihealth Card Number Healthy Behaviors - Choose one of the following statements (1 - 4) 1. Patient does not have health risk behaviors that need to be addressed at this time.
MI_HRA.docx