Owner-Associates – PLEASE READ!!
Directions for completing Physician Upload Form
1. Read all directions before taking the form to your physician.
2. Labs MUST be completed and submitted between October 1, 2014 and September 30, 2015 in order to be accepted by SimplyWell and to be eligible for 2016 HealthyFirst incentives.
3. All owner-associate information must be completed and signed by the owner-associate.
4. The Physician Upload Form is only for owner-associate use. Spouses or domestic partners who want to report a preventive visit should use the Preventive Screening Form.
5. INCOMPLETE information provided by your physician will not be entered and it is your responsibility to ensure all the information is complete to earn the HealthyFirst incentives. Please check with your physician before the form is submitted.
6. For pregnant or nursing mothers, please use biometrics and lab results that were obtained most recently prior to pregnancy.
7. Incomplete or late forms will not be accepted by SimplyWell for any reason.
8. Forms must be received by SimplyWell no later than 5:00 p.m., CST on Wednesday, September 30, 2015.
If this form is received by SimpyWell prior to June 1, 2015, the information will be uploaded into your SimplyWell profile after that date. If received after June 1, 2015, please allow 5-7 business days for information to be loaded into your SimplyWell profile.
As a reminder, your personal health information is protected by HIPAA and no one – even your spouse – can receive this information.
SimplyWell heavily guards your health information, just as First Data guards our clients’ data. First Data does not receive information regarding your health screening. See http://www.firstdatabenefits.us/health-screening-confidentiality/ for more information.
SimplyWell: Lab Results by Medical Provider
Owner-associates, please use this form if you cannot or choose not to participate in an onsite screening event held at many First Data locations in 2015. By completing and submitting this information, you will be eligible for the 2016 HealthyFirst wellness incentives.
To be completed by Owner-Associate Please print legibly and complete the following.
Owner-Associate Name: Company: First Data
Owner-Associate Date of Birth: / / Gender (circle one): M / F
SimplyWell Participant ID: (Owner-Associate= FD plus employee id)
Phone Number: Email address:
**I have read the instructions for submission and understand it is my responsibility to make sure
all information is provided to qualify for my company’s wellness incentive.
Owner-Associate signature:_
To be completed by PHYSICIAN/PROVIDER
Provider Name: (print clearly) Phone:
Provider Address:
**Provider Signature(REQUIRED TO ACCEPT UPLOAD RESULTS):
Date of Lab Results: / /
POST LAB/BIOMETRIC RESULTS -Required Incomplete information will not be entered by SimplyWell.
Height
Weight
Blood Pressure
Fasting Glucose HDL
LDL
Triglycerides
IMPORTANT!
Labs MUST be completed and submitted between October 1, 2014 and September 30, 2015 in order to be accepted by SimplyWell for your HealthyFirst incentives.
Incomplete forms will not be accepted!
PLEASE EMAIL OR MAIL THIS COMPLETED FORM TO:
SimplyWell Account Manager – Elise McHatton
email forms to ,
fax to 402-552-3355 (faxed forms are held in a secure location – your information is protected) or mail to
9140 West Dodge Road, Ste. 408, Omaha, NE 68114
Questions: 1-877-991-9355 OR