2023 PCP Form Instructions for Health Wellness
This file contains instructions for submitting a Primary Care Provider form to Catapult Health. It includes details on how to submit via secure email, fax, or mail. Active employees and retirees can use this form to receive credit toward their wellness incentive.
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How do I fill this out?
To fill out this form, ensure all required fields are completed accurately. Sign and date where necessary, and follow the instructions for your Primary Care Provider. Submit the form using one of the provided methods to Catapult Health by the deadline.
How to fill out the 2023 PCP Form Instructions for Health Wellness?
1
Complete all required fields on the form.
2
Provide your signature and date.
3
Have your Primary Care Provider fill in their section.
4
Submit the form via secure email, fax, or mail.
5
Ensure that Catapult Health received your form by the deadline.
Who needs the 2023 PCP Form Instructions for Health Wellness?
1
Active employees needing to report a PCP checkup for wellness incentive.
2
Retirees who are policyholders with OGB Blue Cross.
3
Participants who missed the Catapult Health Preventive Checkup.
4
Individuals who want to ensure their checkup details are submitted securely.
5
Those looking to receive credit toward the Office of Group Benefits wellness incentive.
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2
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3
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4
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5
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What are the instructions for submitting this form?
Submit the completed PCP form to Catapult Health via secure email at https://securecontact.me/support@catapulthealth.com. Alternatively, you can fax the form to 210-800-9931 or 877-885-9904. Mail submissions should be sent to Catapult Health, 5294 Belt Line Rd, Suite 200, Dallas, TX 75254. Ensure you keep a copy of the form and proof of the date of submission. Follow up with Catapult Health Customer Care if you do not receive a confirmation email within 14 business days of submission.
What are the important dates for this form in 2024 and 2025?
Important dates for this form in 2024 and 2025 will be similar to the 2023 deadline, usually by the end of September each year. Please stay updated with the latest deadlines from Catapult Health.
What is the purpose of this form?
The purpose of this form is to document your Primary Care Provider checkup and submit it to Catapult Health to receive credit toward the Office of Group Benefits wellness incentive. This form must be completed with accurate and thorough information, verified by both the patient and the Primary Care Provider. Timely submission is crucial to ensure that participants receive their wellness incentives without delay.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Name: Includes first, middle initial, and last name.
- 2. Patient's Signature: The patient’s signed authorization.
- 3. Date Signed: The date the form is signed by the patient.
- 4. Date of Birth: The patient’s birthdate in MM/DD/YYYY format.
- 5. Gender: Circle MALE or FEMALE.
- 6. Address: The patient’s residential address, including street or PO Box, City, State, and Zip code.
- 7. BCBS LA Member ID: The patient’s ID number as provided by Blue Cross.
- 8. Phone: The patient’s contact phone number.
- 9. Email: The patient’s email address.
- 10. Provider's Name: The Primary Care Provider’s full name.
- 11. Provider's Signature: The signature of the Primary Care Provider.
- 12. Date of Checkup: The date the checkup was performed.
- 13. Height: The patient’s height in feet and inches.
- 14. Weight: The patient’s weight in pounds (lbs).
- 15. Abdominal Circumference: Measurement of the patient’s abdominal circumference in inches.
- 16. Total Cholesterol: The patient’s total cholesterol level in mg/dL.
- 17. Blood Pressure: The patient’s blood pressure reading.
- 18. HDL Cholesterol: High-density lipoprotein cholesterol level in mg/dL.
- 19. LDL Cholesterol: Low-density lipoprotein cholesterol level in mg/dL.
- 20. Triglycerides: The patient’s triglycerides level in mg/dL.
- 21. Glucose: The patient’s glucose level in mg/dL.
- 22. A1C: Hemoglobin A1C percentage if applicable.
What happens if I fail to submit this form?
Failure to submit this form on time may result in not receiving the wellness incentive credit.
- Missed Deadline: You may miss out on the wellness incentive credit for the year.
- Incomplete Information: Failure to provide all required information could result in processing delays or rejections.
- Lack of Confirmation: Not receiving confirmation of receipt may require resubmission.
How do I know when to use this form?
- 1. Missed Catapult Health Checkup: Use this if you didn’t participate in the Catapult Health Preventive Checkup.
- 2. Wellness Incentive Credit: Submit for credit toward the Office of Group Benefits wellness program.
- 3. Verification: Ensure your checkup is documented and submitted for verification.
- 4. Policyholder Requirement: If you are a Blue Cross policyholder and need to meet wellness incentive requirements.
- 5. Health Documentation: Maintain accurate health records by submitting your checkup details.
Frequently Asked Questions
How do I submit the PCP form?
You can submit the form via secure email, fax, or mail to Catapult Health.
Can I edit the PCP form on PrintFriendly?
Yes, you can use PrintFriendly’s PDF editor to fill out and edit the form.
How do I sign the PCP form digitally?
Use the PrintFriendly editor to add your digital signature and date to the form.
What if I didn’t receive a confirmation email?
Contact Catapult Health's Customer Care Team if you don’t receive an email within 14 business days after submission.
What is the deadline to submit the PCP form?
The deadline for submission is 5:00 pm CST on September 29, 2023.
Can I share the completed form via email?
Yes, PrintFriendly allows you to share the completed form directly via email.
What should I do if my form is incomplete?
Ensure all required fields are filled out, then resubmit the form.
Do I need to keep a copy of the submitted form?
Yes, keeping a copy of the submitted form and proof of the submission date is recommended.
Who can use this PCP form?
Active employees, retirees, and OGB Blue Cross policyholders who need to report a PCP checkup for wellness incentives.
Can I use PrintFriendly to add notes to the form?
Absolutely, use PrintFriendly’s annotation tools to add any relevant notes to the form.
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