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 physician. Employees seeking their screening via their primary care physician 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 physician.  Please email the completed form to or fax it to 317-274-5285.

Please send verification within six months of your screening.

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