Health Screening Verification Form

Want your primary care provider to do your screening? You can still get the incentive.

As a convenience we offer health screenings on-site, but we know many employees want to attain their screening with their primary care provider. Employees seeking their screening via their primary care provider are responsible for any applicable co-pay or deductible. Review your plan document for your specific health plan coverage. Healthy IU is not responsible for co-pays or deductibles.

To verify your screening, you may print and take the Verification of Health Screening form with you to your appointment to be completed by your primary care provider. Please scan and email the completed form to healthyu@indiana.edu or fax it to 317-274-5285.

Any screening completed within the fiscal year is applicable from July 1 – last Friday of May. Please submit your verification form before the last Friday of May to ensure your incentive can be processed before the end of the fiscal year. Late submissions will not be processed.

This form is NOT needed when attaining screening on campus. Screening results should NOT be included on this form.