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If you are NOT part of the SSC medical, dental, or vision plan, but would like to earn points for participation in preventative screenings including but not limited to dental cleanings, mammogram, vision exam, colonoscopy, etc., use this form and have your healthcare provider sign off. No results are needed, just the date you completed the screening and your healthcare provider's signature. Points will be credited to your account within 7 days of receipt of the form by Virgin Pulse.
Date of Birth:
Consent to Use Information. I understand that Virgin Pulse may use personally identifiable information obtained on this Health Care Provider Form, including, but not limited to, my name, date of birth, and screening results (my "Personal Information") to provide health management services to me, which includes using the Personal Information to inform me of relevant health related and health education programs offered by Virgin Pulse or by another service contractor. In the event that Virgin Pulse's services are transitioned to another service provider, Virgin Pulse may deliver my Personal Information to the successor provider to maintain a continuity of services for me.
I certify that the information supplied on this form has been provided to me by my health care provider, and I understand that Virgin Pulse may contact my health care provider listed on this form with questions regarding my information.
|Screening Exam||Frequency||Completed Date||HCP Signature|
|Dental Exam/Cleaning||2 x Year|
|Bone density test||Annually|
|Colorectal cancer screening||Annually|
|Breast cancer screening||Annually|
|Cervial cancer screening||Annually|
|Pregnancy glucose test||Annually|
|Prostate cancer screening||Annually|
|Skin cancer screening||Annually|
*Allow 7 business days for processing