Health Enhancement Program - State of Connecticut …

State of Connecticut

Health Enhancement Program

CO-1316 Revised 5/2012

COMPLIANCE NOTIFICATION FORM

State Of Connecticut Office of the State Comptroller Healthcare Policy & Benefit Services Division

55 Elm Street Hartford, CT 06106-1775

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Important Information

The Health Enhancement Program rewards members for taking steps to help maintain good health or to achieve greater health. One important step for members to remain eligible for program participation is to complete their regular health screenings. There may be times when claims data is not available to identify a member's completion of a requirement. This form should be used to report information for those times where data was unavailable, but a requirement was in fact already completed. There may also be times when a requirement cannot be completed due to medical reasons. If a requirement cannot be met due to a special circumstance medical condition (for example, pregnancy, etc.) or if it is medically unadvisable, you may also use this form to request an exemption.

If you were not notified of missing HEP requirements, then you do not need to use this form. Your health plan will be able to automatically identify your completion of a requirement through claims submitted by your physician or provider.

INSTRUCTIONS FOR MEMBERS: Please complete the Member Information and the Provider Information sections of this form. Please self-report your completion or scheduled completion of a physician visit or screening on page 2. Once completed, please submit forms as noted below. Your form will be processed within 15 business days from receipt as long as all required information is submitted. If you have questions regarding this form or the HEP program, please contact your State-dedicated Member Services Department on the back of your medical carrier's ID card.

Submit completed Compliance Notification forms to: Healthcare Analysis Unit, Office of the State Comptroller, 55 Elm Street, Hartford, CT 06106 or fax to: (860) 702-3556.

If your reported screening was processed through insurance outside of your state-sponsored health coverage or if you are requesting an exemption you MUST also submit a Physician Notification form to your medical carrier.

Member Information (Required and must match exactly to what is listed on your Medical/Dental Plan ID card.) Employee ID

Employee Last Name Spouse Last Name

Employee First Name Spouse First Name

Middle Initial

Date of Birth (MM/DD/YYYY)

/

/

Middle Initial

Home Address ? Number and Street Name

City

State

Zip Code

Telephone

(

)

-

Email Address

Medical Provider Information (Required)

Provider Name / Name of Clinic

Provider ID # (If Applicable) Telephone

(

)

Office Address ? Number and Street Name

City

State

Fax

(

)

-

Zip Code

Dental Provider Information (If Applicable)

Dentist / Provider Office Name

Provider ID # (If Applicable) Telephone

(

)

Office Address ? Number and Street Name

City

State

Fax

(

)

-

Zip Code

State of Connecticut ? HEP ? Compliance Notification Form Page 2 of 2

Employee/Spouse Last Name

Employee/Spouse First Name Middle Initial

Date of Birth (MM/DD/YYYY)

/

/

Place Check Mark in Each Applicable Box

Service or Appointment

Date

(MM/DD/YY)

Completed/Scheduled Screening

Future Appointment

Scheduled

Already Completed

Already Completed

Processed With Coverage Outside of State-Sponsored Medical or Dental Insurance

Exempted from

Screening

Preventive Well Visit Exam

Cholesterol Screening

Once every: 5 years (ages 20-29), 3 years (ages 30-39), 2 years (ages 40-49) and every year (ages 50+)

Vision Exam

(Adults 19 and older, every other year)

Clinical Breast Exam (Females Only)

Adults 18 and older, once every 3 years

Mammography

Required for every female between the ages of 35 and 39 or as recommended by Physician

Colorectal Cancer Screening

Fecal Occult annually or Colonoscopy every 10 years

Cervical Cancer Screening

(ages 21+) One screening required every 3 years

Dental Cleaning(s)

(If enrolled in a State dental plan)

/ / / / / / / / / / / / / / / /

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

I understand that I am responsible for submitting a completed Physician Notification Form to be considered compliant with HEP requirements.

Employee/Spouse or Parent/Legal Guardian Signature

Date

X_____________________________________________________________

/

/

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