How to Fill Out and Submit the PEEHIP Wellness Screening Form

The PEEHIP Wellness Screening Form is a one-page document that captures your biometric health data and goes to the Alabama Department of Public Health so you can avoid a $50 monthly wellness premium surcharge. If your primary care provider performs the screening, you fill out Section 1 yourself, your provider completes Section 2 with your measurements, and you fax or mail the finished form to ADPH by August 31. If ADPH staff or a participating pharmacy screens you instead, they submit the data directly and you never handle the form.¹

Who Has to Complete a Screening

The wellness premium applies separately to each person on the plan, so if both you and your spouse are covered, each of you needs a completed screening to avoid the surcharge on your account.² These people enrolled in the PEEHIP Hospital Medical Plan Group #14000 are subject to the requirement:

Active employees of a PEEHIP participating system, along with their covered spouse regardless of Medicare eligibility.
Non-Medicare-eligible retirees.
Non-Medicare-eligible spouses on a retiree contract.
Non-Medicare-eligible members on COBRA, leave of absence, and surviving spouses.

The screening itself is voluntary. PEEHIP cannot force a medical exam, but skipping it means the $50 monthly premium starts automatically in October and stays on your account for the full plan year with no mid-year fix.³p>

Three Ways to Get Screened

Where you get screened decides whether you ever touch the paper form.

Alabama Department of Public Health

ADPH nurses hold free screenings at PEEHIP worksites and at county health departments across the state. Scheduled events are listed on the ADPH online calendar.⁴ When ADPH performs the screening, they submit your data directly and no Healthcare Provider Screening Form is needed.

Participating Network Pharmacy

Screenings are also free at participating pharmacies, including major chains and independent pharmacies on the authorized list.⁵ The pharmacy handles submission; you do not fill out the form.

Your Primary Care Provider

You can have a physician, nurse practitioner, or other licensed provider do the screening at an office visit. PEEHIP covers one preventive routine office visit per calendar year with no copay when the provider is in-network, though lab work like blood draws may still carry copays. This is the route that uses the Healthcare Provider Screening Form, and it is your responsibility to get the completed form to ADPH.³

Filling Out Section 1

Download the Healthcare Provider Screening Form from the PEEHIP wellness page at rsa-al.gov. The whole form must be completed in black ink, printed clearly, with all applicable boxes darkened. Incomplete forms are not processed.³

You fill out the top section yourself before or during your appointment. The fields are:

PEEHIP PID (your personal identification number, not your contract number).
Last name, first name, middle initial, and birth date.
Patient Social Security number.
Zip code and gender.
Status: contract holder or spouse.
Whether you have used a tobacco product or electronic smoking device in the last 12 months.
Race and ethnicity.
Medical history checkboxes for high cholesterol, high blood pressure, and diabetes.
Medication checkboxes for the same three conditions.
Your signature.

Section 1 also carries a checkbox at the bottom for members who cannot be screened due to pregnancy or disability.¹

What the Provider Records in Section 2

Your provider records the clinical readings during the appointment:

Blood pressure.
Height and weight.
BMI, calculated from height and weight.
Blood glucose.
Total cholesterol, HDL, and LDL.
Triglycerides.

The provider also prints their name, provider type, address, and phone number, and signs the form. A form missing the provider’s signature or any of the biometric fields will be rejected, so confirm every field is legible and filled before you leave the office.

Where to Send the Completed Form

When your own provider does the screening, submission is on you. The form can only be sent two ways, and there is no online upload.³

Fax: 334-206-0385 or 334-206-0394.

Mail: ADPH Wellness Program, 201 Monroe Street, Suite 986, Montgomery, AL 36104.

Faxing gives you a transmission confirmation the same day. If you mail the form, use tracked delivery; the form must reach ADPH by August 31, not simply be postmarked by that date.

The Screening Window and What a Miss Costs

For the plan year that begins October 1, 2026, your screening must be completed and the form received by ADPH between August 1, 2025, and August 31, 2026. A screening performed outside that window does not count toward the waiver, even if the results are otherwise valid.¹

Miss August 31 and the $50 monthly wellness premium starts with the October payment cycle and runs the full plan year. There is no way to submit a late screening and remove the surcharge mid-year. The cycle resets annually, so a new screening is required each year to keep the waiver.²

Confirming It Was Received

Log in to Member Online Services at rsa-al.gov and look under PEEHIP Services for your Wellness Completion Status. The portal shows whether the requirement is marked complete for the current screening year.¹ Check it well before August 31. Faxes occasionally fail and forms occasionally get rejected for illegibility, and you want time to resubmit. If your status still reads incomplete a couple of weeks after you submitted, call ADPH or PEEHIP to follow up.

If Pregnancy or Disability Prevents a Standard Screening

Members who cannot complete a standard screening because of pregnancy, a disability, or another medical condition can request a reasonable accommodation or alternative standard and still earn the waiver. Alternatives are handled case by case. Call PEEHIP at 877-517-0020 for instructions, and note that the accommodation still has to be completed inside the same August 1 through August 31 window.¹

1
Public Education Employees’ Health Insurance Plan. PEEHIP Wellness
2
Public Education Employees’ Health Insurance Plan. PEEHIP Member Handbook 2025-2026
3
Public Education Employees’ Health Insurance Program. PEEHIP Wellness Screening Form and Notice
4
Alabama Department of Public Health. Worksite Wellness
5
Retirement Systems of Alabama. Alabama Participating Pharmacies for Free Wellness Screenings