Fill in a Valid Inova Health Screening Template

The Inova Health Screening form is a document designed to collect essential health information from patients participating in health screenings. This form ensures that providers have the necessary details to conduct thorough health assessments while maintaining compliance with privacy practices. To take the first step toward your health assessment, fill out the form by clicking the button below.

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The Inova Health Screening form serves as a critical tool for individuals participating in health assessments, ensuring that accurate information is collected for effective health screenings. This form is designed for various participants, including employees, spouses, and domestic partners. It requires personal information such as name, address, contact details, and date of birth, which helps establish the patient's identity. The form also inquires about past participation in health screenings and asks for consent related to the testing of samples submitted to Health Diagnostic Laboratory, Inc. Furthermore, it outlines important aspects regarding patient responsibility for follow-up care with primary physicians after receiving test results. Acknowledgment of privacy practices is necessary, reflecting the importance of patient confidentiality. The form concludes with sections dedicated to biometric measurements, which include height, weight, blood pressure, and waist circumference, all essential data for assessing an individual's health status. Proper completion of the form, indicated by specific instructions, is vital for ensuring that the health assessment appointment proceeds smoothly.

Inova Health Screening Example


«Please select one
Employee Spouse or Domestic Partner

PATIENT ID	«		ID	«	HISTORY
	EMPLOYEE			«
				Did you participate in the Inova Health
				Screening in 2014? Yes  No 
	PATIENT INFORMATION
«Last Name:		First:			Middle Iniial:

«Address (Home or Mailing):

	«City:					«State:		«Zip Code:
	«Primary Phone:					«Date of Birth:			«Age:
(				)	-	/	/
		«Secondary Phone:				«Sex:
(				)	-	M		F
			«Email:			«Employer Name:
					YOUR PHYSICIAN	INFORMATION
«Physician’s Name:						«Pracice Name:

«Pracice Phone Number:

PATIENT CONSENT

I consent to submit my sample to Health Diagnostic Laboratory, Inc (“HDL”) for testing. HDL works with physicians who will order your laboratory test(s) when medically appropriate. These physicians will not diagnose or treat you. The blood testing service from HDL (a) is provided solely for informational purposes and does not constitute treatment or diagnosis of any medical condition or the practice of medicine; and (b) is not being used as a substitute for the care, medical advice, or treatment provided by your primary care physician. You are solely responsible for forwarding your test results to your primary care physician and following up with that individual. HDL and HDL physicians shall not be liable for your failure to consult with your primary care physician or another medical professional following receipt of test results. When you participate in a blood test from HDL, you are doing so with the understanding that you/your employer is privately paying for these tests and there will be absolutely no billing to Medicare, Medicaid, or private insurance. I have read the above terms and conditions and agree to them.


	/	/
	/	/
Patient Signature	Date

	NOTICE OF PRIVACY PRACTICES

I acknowledge that I have reviewed HDL Notice of Privacy Practices and understand that it may be revised from time to time. I understand that any changes will be posted on HDL’s website, www.hdlabinc.com, and that I am entitled to receive a copy of the notice upon request.

«	/	/
Patient Signature	Date

Office Use Only:

We attempted, but could not obtain written acknowledgment of receipt of our Notice of Privacy Practices, because:

Patient refused to sign

Emergency Situation

Other:__________________________________________________________________________________

PHLEBOTOMIST USE ONLY

Has the Paricipant previously had their

YES

If yes, where?

labs drawn by HDL?

Is the Paricipant

YES

Does the Paricipant have a

YES

pregnant?

pacemaker?

Biometrics

Drawing Lab:

Height:

feet

inches

Tel. No.:

)

Weight:

(

ext:

pounds

Collecion Date & Time:

Blood

Pressure

am/pm

(mm/Hg):

Systolic

Diastolic

Phlebotomist

Waist

Circumference

(inches):

inches

Fasing:

Yes

Body Composiion (%):

Hrs

Internal Use Only:  All fields with a «are complete.

Location is checked.

Phlebotomist Use Only is complete.

Initial:_______ Date:________

*INSTRUCTIONS:

This form MUST be typed, signed, printed and brought to your health assessment appointment. Handwritten copies will NOT be accepted.

REQUESTING LAB/INSTITUTION

Inova WellAware Health Screening	V1.3
Inova WellAware Health Screening
HDL Overseeing Physician: Thomas D. Dayspring, MD

«Please select your location of employment, or "spouse" if applicable

Inova Fairfax Medical Campus - 0010898

Inova Alexandria Hospital - 0010899

Inova Fair Oaks Hosptial - 0010900

Inova Loudon Hosptial - 0010901

Inova Mount Vernon Hospital - 0010902

Inova Medical Group - 0010903

Inova Continuum of Care - 0010905

Inova Healthplex-Urgent Care Centers - 0010906

Inova System Office - 0010904

Inova Spouse-Domestic Partner - 0010907

CUSTOM PANELS

Custom Employer Panel

Lipid Panel hsCRP Insulin Glucose HbA1c

TSH

ALT Creatinine Cystatin C LDL-P & HDL-P

Joseph P. McConnell, Laboratory Director 737 N. 5th Street, Suite 103

Richmond, VA 23219

CLIA No. 49D1100708 | CAP No. 7224971 | NPI No.

1629209853

Click for Inova Health Screening File

File Breakdown

Fact Name	Detail
Participant Categories	The form allows selection between Employee, Spouse, or Domestic Partner for participation.
Year of Screening	Participants are asked if they participated in the Inova Health Screening in 2014.
Patient Consent	Participants must consent to submit their samples to Health Diagnostic Laboratory, Inc.
Privacy Practices	Participants acknowledge reviewing HDL's Notice of Privacy Practices, which can change over time.
Billing Information	No billing will occur through Medicare, Medicaid, or private insurance for these tests.
Forms Requirement	The form must be typed, signed, and printed before attending the health assessment appointment.
Custom Panel Options	Custom panels include various tests such as Lipid Panel, Insulin, and TSH among others.
Governing Law	The form is subject to Virginia healthcare regulations, relevant to the Inova Health System.

Guide to Using Inova Health Screening

Completing the Inova Health Screening form requires careful attention to detail. Following the steps below will help ensure that all necessary information is provided accurately and comprehensively. Make sure to complete the form before your health assessment appointment, as handwritten versions will not be accepted.

Begin by indicating your relationship status by selecting either Employee, Spouse, or Domestic Partner.
Enter your Patient ID if applicable.
For the HISTORY section, select whether you participated in the Inova Health Screening in 2014 by checking either Yes or No.
Fill in the PATIENT INFORMATION section, providing your Last Name, First Name, Middle Initial, Address, City, State, Zip Code, Primary Phone, Date of Birth, Age, Secondary Phone, Sex (Male or Female), and Email.
In the EMPLOYER NAME field, write the name of your employer.
Provide your PHYSICIAN INFORMATION by entering your Physician’s Name, Practice Name, and Practice Phone Number.
Read the PATIENT CONSENT section carefully and acknowledge your consent to submit your sample for testing. Sign and date in the required fields.
Review the NOTICE OF PRIVACY PRACTICES and provide your signature and date of acknowledgment.
In the PHLEBOTOMIST USE ONLY section, indicate if you have previously had labs drawn by HDL and whether you have any specific conditions like pregnancy or the presence of a pacemaker. Fill out any requested biometric information, including height, weight, blood pressure, and waist circumference.
Check that all fields marked with a « are complete and that the Location and Phlebotomist Use Only sections are filled out adequately.
Complete the REQUESTING LAB/INSTITUTION section by selecting your location of employment from the options listed.
Choose any CUSTOM PANELS needed by checking the appropriate fields.

Before attending your appointment, ensure that the form is typed and printed. Handwritten copies will not be accepted. Double-check for any missing information, as incomplete forms may delay your health screening process.

Get Answers on Inova Health Screening

What is the purpose of the Inova Health Screening form?

The Inova Health Screening form serves as a necessary document for individuals participating in health assessments through Inova. It collects essential personal and medical information to facilitate blood testing services. This process helps track health metrics and is designed to promote preventive health measures.

Who should complete the Inova Health Screening form?

Both employees and their spouses or domestic partners are eligible to complete the form. The form requires basic identifying information to ensure accurate testing and results. This includes details such as name, address, date of birth, and contact information.

Is there a cost associated with the blood tests?

Yes, participants may incur costs associated with the blood tests, as these tests are privately paid. There will be no billing to Medicare, Medicaid, or private insurance. Participants should be aware that they, or their employers, will be responsible for all costs associated with these services.

What information is required on the form?

The Inova Health Screening form requires various details, including:

Personal information: Name, address, phone numbers, email, and date of birth.
Employment details: Name of employer and specific location of employment.
Medical information: Name and contact details of the primary physician.
Consent signatures: Participants must provide consent for labs and acknowledge privacy practices.

What happens if I do not have prior lab results?

Inova may ask if you have previously had labs drawn by Health Diagnostic Laboratory, Inc. If you have not, simply select the appropriate responses on the form. Your current screening and lab tests will still proceed as planned since the form does not require previous results to initiate new tests.

How is my privacy protected when completing this form?

Inova is committed to protecting your privacy. Upon completion of the Inova Health Screening form, you will need to acknowledge that you have reviewed the Notice of Privacy Practices provided by Health Diagnostic Laboratory, Inc. Changes to this notice will be posted on their website, and participants are entitled to request copies at any time.

What should I do if I experience difficulty completing the form?

If you encounter difficulties while filling out the form, consider reaching out to the designated health screening coordinator or your employer's HR department for assistance. They can provide clarification on specific fields or requirements of the form. Completing the form accurately is essential for a successful testing process.

Signing the consent section of the form indicates your agreement to submit samples for testing and acknowledges the limitations of the services provided. This section clarifies that the testing is strictly for informational purposes and not a substitute for professional medical advice or treatment. It is vital to understand the implications of consenting to these tests.

What should I bring to my health assessment appointment?

Participants are required to bring a printed and signed copy of the Inova Health Screening form to their health assessment appointment. Handwritten forms will not be accepted, so ensuring that your form is typed and complete is crucial for a smooth experience on the day of your appointment.

Common mistakes

Filling out the Inova Health Screening form requires careful attention to detail. One common mistake is selecting the wrong category for the patient. The form explicitly asks to select between "Employee," "Spouse," or "Domestic Partner." Choosing the incorrect option can lead to processing delays and potential issues with test results.

Another frequent oversight involves providing incomplete personal information. Essential fields, such as Last Name, First Name, and contact details, must be filled out accurately. Omitting or misplacing a digit in the Primary Phone number or the Date of Birth can hinder communication regarding test results.

People often neglect to indicate their employment location correctly. Ensuring that the selected employment location is accurate is crucial for accurate record-keeping. Each facility has a unique identifier, and selecting the wrong one may result in complications during the appointment process.

Inadequate signatures can also cause problems. The form requires a clear signature from the patient in multiple sections. If the signature is missing or illegible, it may lead to administrative challenges, including a lack of consent for testing.

Not understanding the consent section is another mistake many make. Participants must acknowledge that they are privately paying for the tests and that the services do not imply medical treatment. Failing to read this section thoroughly can lead to misunderstandings regarding the testing process.

Some individuals forget to confirm biometric measurements. Accurate data on Height, Weight, and Waist Circumference is vital for the health assessment. Missing or inaccurate values can affect the interpretation of test results and patient health evaluations.

People may overlook the Collection Date & Time. This information is necessary for accurate record-keeping and ensures that the lab can appropriately track when the samples were taken.

One significant error occurs when individuals do not bring a typed form to their appointment. Handwritten forms are not accepted. Forgetting this requirement leads to rescheduling and delays in the screening process.

Lastly, neglecting to review the Notice of Privacy Practices is a common error. Understanding these practices safeguards patients' rights and ensures compliance with regulations. Skipping this step may result in confusion regarding privacy and the use of personal health information.

Documents used along the form

The Inova Health Screening form is an essential document used for health assessments within the Inova Health system. In addition to this form, several other documents may accompany it, facilitating a comprehensive health evaluation process. The following list outlines commonly used forms and documents.

Patient Consent Form: This document ensures that patients agree to the testing procedures and understand that the results are for informational purposes only, not a substitute for professional medical advice.
Notice of Privacy Practices: This form details how personal health information will be used and protected. Patients must acknowledge their understanding of privacy practices prior to testing.
Lab Test Request Form: This document specifies the laboratory tests to be performed. It includes information necessary for processing, including patient details and the specific tests requested.
Biometric Data Collection Form: This form records various biometrics such as height, weight, and blood pressure. This data is essential for assessing overall health during the screening.
Physician Referral Form: If follow-up care is needed, this form facilitates communication between health providers, allowing for more coordinated care based on test findings.

Each of these forms plays a critical role in ensuring a thorough and effective health screening. They help safeguard patient rights while ensuring the accuracy and confidentiality of health data. Proper completion and understanding of all related documents are vital for optimal care and record-keeping.

Similar forms

The Inova Health Screening form shares similarities with several other important documents used in healthcare settings. Each document serves distinct yet comparable purposes related to patient information and consent. Here are five documents that are similar to the Inova Health Screening form:

Medical History Form: Like the Inova form, a medical history form collects personal details about the patient, including past medical conditions, family history, and current medications. These forms help healthcare providers understand a patient’s health background before treatment or testing.
Informed Consent Form: This document, much like the Inova Health Screening form, ensures that patients are fully aware of the procedures they will undergo. It outlines the risks and benefits, enabling patients to make informed decisions about their health.
Patient Registration Form: Similar to the Inova Health Screening form, a patient registration form gathers essential information such as demographics, contact details, and insurance information. It streamlines the process of patient intake for healthcare practices.
Privacy Notice Acknowledgment Form: This document aligns with the privacy practices acknowledged in the Inova Health Screening form. It informs patients how their health information will be used and shared, fostering transparency and trust in the provider-patient relationship.
Laboratory Requisition Form: Just as the Inova Health Screening form includes consent for blood testing, a laboratory requisition form requests specific tests from a laboratory. It includes necessary patient identifiers and tests requested, ensuring proper handling of samples.

Dos and Don'ts

When filling out the Inova Health Screening form, following some guidelines can make the process smoother and more efficient. Here are some important dos and don’ts to keep in mind.

Do ensure that all required fields are filled out completely. Missing information may delay your screening.
Do use a computer to type the form. Handwritten forms will not be accepted.
Do double-check the accuracy of your contact information. This ensures you receive any necessary follow-up.
Do bring the completed form to your health assessment appointment. It is essential for facilitating your testing.
Don't skip reading the consent and privacy practices sections. Understanding your rights is important.
Don't leave any required signatures blank. An incomplete form can lead to complications later.
Don't provide misleading or false information. This can affect the accuracy of your health records.
Don't forget to check your appointment date and time to avoid any scheduling conflicts.

By adhering to these guidelines, you help facilitate a smoother screening process and ensure your health information is correctly documented.

Misconceptions

When it comes to the Inova Health Screening form, there are many misconceptions that can lead to confusion. Let's clear some of them up!

Only Employees Can Use the Inova Health Screening - Many believe that only employees can get screened; however, spouses and domestic partners are also eligible.
This Form Is Only for Existing Patients - New patients can also fill out the form for their first screening.
Handwritten Forms Are Acceptable - Some think it's fine to submit handwritten forms, but typed and signed documents are a must.
The Screenings Are Covered by Insurance - Participants should know that these tests are privately paid by the individual or employer; insurance billing is not available.
All Results Are Automatically Sent to Your Physician - It’s crucial for patients to actively forward their results to their primary care physician after testing.
Blood Tests Provide a Diagnosis - Testing through HDL is for informational purposes only and does not diagnose any medical conditions.
Privacy Practices Are Optional - Acknowledging the Notice of Privacy Practices is necessary; participants should fully understand their rights regarding personal health information.
Pregnancy Does Not Affect Participation - Pregnant participants need to be aware that this testing may require extra considerations.
Only Basic Information Is Collected - The form collects various data, including medical history, contact information, and specifics on previous lab tests.
All Lab Tests Are Included in One Price - Different tests can have separate costs and may not be covered under one fee, so it’s best to check beforehand.

Understanding these points can help you navigate the Inova Health Screening form with confidence. It's all about making informed decisions about your health!

Key takeaways

Completing the Inova Health Screening form accurately is key to ensuring your health information is processed correctly. Here are some essential takeaways to consider:

Types of Participants: You must select whether you are an employee, spouse, or domestic partner at the beginning of the form.
Patient Information: Fill in all relevant details such as your name, address, contact numbers, and date of birth.
Physician Information: Include your physician's name and practice information to facilitate communication regarding your lab results.
Patient Consent: You will need to sign to consent to submit samples for testing. Understand that these tests are for informational purposes only and do not replace medical advice.
Submission Requirements: Ensure the form is typed, signed, and printed. Handwritten forms will not be accepted at your health assessment appointment.

Careful attention to these details can help streamline your experience and ensure you receive comprehensive care.