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Enclosed is a physician results form that will allow your doctor to perform your 2015 biometric wellness
screening. To use this screening option, laboratory results must be collected between October 1, 2014
and April 30, 2015. You are responsible for ensuring your doctor faxes the form directly to Quest
Diagnostics, complete with all screening values and signatures, by May 15, 2015. Results received
in any other format or without required information will not be accepted. If the form is received after the
deadline, you will not receive the participation credit for the program.
Please follow these steps carefully:
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Schedule an appointment with your doctor by April 30, 2015. If you have already had your annual
preventive care visit, your doctor’s office may charge office visit copay. In addition, your doctor may
apply a fee for completing the form. You are responsible for paying any such copays and/or fees.
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Contact your doctor’s office prior to your appointment to confirm he/she is able to measure all
required measures. Please see below for the measures that are required for the program. Forms
that do not include results for all factors will not be processed.
Required Test:
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Height
Weight
Blood pressure
Glucose
Total Cholesterol
Triglycerides
LDL
HDL
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You must sign and date the Wellness Participant section of the enclosed Physician Results Report
Form before providing the form to your doctor.
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Your doctor must fax the completed form to Quest Diagnostics at (855) 794-1391. You are
responsible for ensuring your doctor returns this form by May 15, 2015.
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If your form is complete with the required risk factors you will receive your results online within 10
days and a paper report in the mail within 3 weeks of submitting the form. If you have not received
your results within the timeframe described above, please contact the Blueprint for Wellness
Customer Support Center at (866) 908-9440.
Physician Results Form
Completed form must be faxed to 855-794-1391
Patient’s Employer Wellness Program Information
Company Vanguard Group Inc
Wellness Participant Completes
Wellness Participant Name (Last, First, Middle Initial)
Email Address
Date of Birth (MM/DD/YYYY)
Crew ID
Phone
Address
City
State
Zip Code
Wellness Participant Signature
Date
The information provided on this form will be kept confidential.
Physician Office Completes
Date of Test
Testing and measurements must have been completed between these dates:
October 1, 2014 - April 30, 2015
Biometric Screening
Measurement
Screening Values
Enter NG for any result not available for reporting.
Height (inches) (Required)
Height (feet) (Required)
Blood Pressure (Required)
Systolic
Weight (lbs) (Required)
Diastolic
Glucose mg/dL (Required)
Total Cholesterol mg/dL (Required)
Triglycerides mg/dL (Required)
LDL Cholesterol mg/dL (Required)
HDL Cholesterol mg/dL (Required)
Physician Office
Physician or Physician Designee’s Signature
Date
Physician or Physician Designee's Signature
Physician’s Name (please print)
UPIN/NPI
Internal Use ONLY
Blueprint Project Name
Wellness Participant Information:
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Physician Results Form option is available for those participants who cannot participate at an
on-site event or Patient Service Center. By submitting this form, you are requesting your physician to report
laboratory and biometric results to Quest Diagnostics for your Health Risk Screening.
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You are responsible for ensuring your doctor returns this form by the deadline. Your results will not be
processed if your form is received after May 15, 2015.
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For an individual participant only one physician form can be submitted.
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Physician results cannot be combined with or used to override any actual measured results by Quest
Diagnostics.
For questions please contact the Blueprint for Wellness Customer Support Center by email at
[email protected] or by calling 866-908-9440 available (Monday – Friday 7 a.m. – 8:30 p.m. CST and
Saturday 7:30 a.m. – 4 p.m. CST).
Quest, Quest Diagnostics, the associated logo, Blueprint for Wellness and all associated Quest Diagnostics marks are the registered
trademarks of Quest Diagnostics. © 2000-2014 Quest Diagnostics Incorporated. All rights reserved.