To submit the Kentucky Employees' Health Plan Biometric Screening Form, you can choose one of the following methods: Securely upload your completed form online at https://totalwellnesshealth.com/gravity-landing/KEHP/ for immediate acknowledgement. Alternatively, you can fax the form securely to 402-939-0604. If you prefer to mail it, send to TotalWellness, Attn: Data Team, 9320 H Court, Omaha, NE 68127. Ensure that your form is received by the deadline of 12/15/2023.

Important dates for 2024 and 2025 include the ongoing validity of this form for any screenings that occur within the specified range. Keep in mind that submission deadlines remain the same annually unless updated by the Kentucky Employees' Health Plan. Always check with your employer for the latest deadlines.

The primary purpose of this form is to collect and report biometric health screening results as part of the Kentucky Employees' Health Plan. It ensures that members engage in wellness programs and receive necessary feedback on their health metrics. By submitting this form, members can access health benefits and maintain compliance with program requirements.

• 1. First Name: The member's first name.
• 2. Last Name: The member's last name.
• 3. Date of Birth: The member's date of birth (mm/dd/yyyy).
• 4. Unique ID: The last four digits of the member's Social Security Number.
• 5. Email: A valid email address for form receipt confirmation.
• 6. Gender: The member's gender.
• 7. Biometric Screening Information: Fields for reporting health metrics from the screening.
• 8. Certified Signature: The healthcare provider's signature to validate the screening.

Failure to submit this form can result in non-compliance with health program requirements, leading to the loss of benefits. Members may miss critical health evaluation opportunities and face challenges in receiving incentives or rewards associated with timely screening. It is crucial to adhere to the submission deadlines to avoid these repercussions.

• Loss of Health Benefits: Missing the deadline may result in the inability to access wellness program benefits.
• Ineligibility for Incentives: Delayed or absent submissions can disqualify members from receiving health incentives.
• Missed Health Evaluations: Members may miss out on necessary health check-ups that could impact their health management.

• 1. During Annual Wellness Checks: When members undergo their annual health examinations.
• 2. For Tracking Progress in Health Programs: To report health metrics for personal wellness tracking.
• 3. For Healthcare Provider Documentation: To provide necessary health data for employer wellness programs.