How to Fill Out and Submit the PEEHIP Healthcare Provider Screening Form

The PEEHIP Healthcare Provider Screening Form is the one-page document your doctor completes after a wellness screening so you can earn the $50-per-month wellness premium waiver. You fill in Section 1 with your member information, your provider fills in Section 2 with your biometric results, and the signed form goes to the Alabama Department of Public Health by fax or mail. For the current plan year, ADPH must receive it by August 31, 2026, and the waiver takes effect October 1, 2026.1Retirement Systems of Alabama. PEEHIP – Wellness

Do You Actually Need This Form?

Only if you’re having your own doctor perform the screening. PEEHIP accepts three ways to meet the wellness requirement, and two of them skip the paperwork entirely:

  • An ADPH on-site event, often hosted by school systems during the year. The ADPH nurse reports your results directly.
  • A BCBS in-network pharmacy that offers biometric screenings. The pharmacy reports the results.
  • Your primary healthcare provider. This is the only path where you handle the Healthcare Provider Screening Form yourself.

All three options are free for PEEHIP members and covered spouses.1Retirement Systems of Alabama. PEEHIP – Wellness

One boundary worth confirming before you fill anything out: the wellness premium applies only to members and covered spouses on the PEEHIP Hospital Medical Plan Group #14000 administered by Blue Cross Blue Shield. If you’re on a different PEEHIP plan, you don’t owe the premium and don’t need the form. Dependent children, Medicare-eligible retirees, and Medicare-eligible spouses of retirees are also exempt from the requirement.1Retirement Systems of Alabama. PEEHIP – Wellness

Section 1: What You Fill In

You complete the top half of the form before (or at) your appointment. It asks for:

  • Your PEEHIP PID number (not your contract number)
  • Full name, Social Security number, date of birth, zip code, and sex
  • Whether you are the contract holder or a covered spouse
  • A race and ethnicity field with seven options
  • Three health-history questions on high cholesterol, high blood pressure, and diabetes, and whether you take medication for any of those conditions
  • A tobacco-use question covering tobacco products and electronic smoking devices in the last twelve months

At the bottom of Section 1 you sign and date the form. Your signature confirms you’ve read the enclosed privacy notice and agree to the disclosure of your health information as described there.2Retirement Systems of Alabama. PEEHIP Healthcare Provider Screening Form and Notice

A checkbox at the bottom of Section 1 lets you flag that the screening can’t be performed because of pregnancy or disability. If that applies, mark the box and call PEEHIP at 877-517-0020 to arrange a reasonable alternative.1Retirement Systems of Alabama. PEEHIP – Wellness

Section 2: What the Provider Fills In

During the visit, your healthcare provider records the biometric results in Section 2:

  • Blood pressure
  • Blood glucose (mg/dL)
  • Total cholesterol (mg/dL)
  • HDL cholesterol (mg/dL)
  • LDL cholesterol (mg/dL)
  • Triglycerides (mg/dL)
  • Height (feet and inches)
  • Weight (pounds)
  • BMI

The provider then prints their name, provider type, office address, and phone number, and signs the form. There’s no field for an NPI number; the printed name, address, and signature are how ADPH verifies the screening.2Retirement Systems of Alabama. PEEHIP Healthcare Provider Screening Form and Notice

Both signatures are required. A form missing either yours or the provider’s will not be processed.

Where to Send the Form

The completed form goes to the Alabama Department of Public Health, not to PEEHIP or RSA. Two submission methods are approved on the form:

  • Fax: 334-206-0385 or 334-206-0394
  • Mail: ADPH Wellness Program, 201 Monroe Street, Suite 986, Montgomery, AL 36104

There’s no online upload option through the PEEHIP Member Online Services portal for this form.2Retirement Systems of Alabama. PEEHIP Healthcare Provider Screening Form and Notice Keep your fax confirmation page, or send by certified mail, so you can prove delivery if the waiver doesn’t post.

Deadline and What’s at Stake

The screening window for the current plan year runs from August 1, 2025, through August 31, 2026. ADPH must have your completed form by August 31, 2026, for the waiver to take effect October 1, 2026.1Retirement Systems of Alabama. PEEHIP – Wellness

Without the waiver, the wellness premium adds $50 per month to your PEEHIP premiums, or $600 over a year. A covered spouse who skips the screening pays a separate $50 per month, so a household with both a member and a covered spouse could owe up to $1,200 in wellness premiums annually. Each person who completes a screening clears their own share.3Retirement Systems of Alabama. PEEHIP Premiums

If You Can’t Complete the Standard Screening

Pregnancy, disability, or another medical condition doesn’t lock you out of the waiver. Check the appropriate box in Section 1 and call PEEHIP at 877-517-0020 to request a reasonable alternative. The program cannot deny the waiver solely because a medical condition made the standard screening impossible or medically inadvisable.1Retirement Systems of Alabama. PEEHIP – Wellness

Confirming the Waiver Posted

Allow several weeks after submission for ADPH to reconcile your screening against PEEHIP records. You can log into the PEEHIP Member Online Services portal from the top of any page on the RSA website to check whether your wellness requirement shows as satisfied. If you submitted well before the deadline and the waiver hasn’t posted by mid-September, call PEEHIP at 877-517-0020 with your fax confirmation or mailing receipt ready.