Awareness Health Screening Event Request

We look forward to working with you and your employee group to provide a successful Awareness Health Screening event. This request form is the first step in the planning process and will help us learn some preliminary specifics about your event and how we can best serve you. After submitting your completed form, you will receive a phone call from our Awareness Program Coordinator.


Name *
Name
Please provide the name of the primary contact person for your Awareness Health Screening event.
Organization Billing Address
Organization Billing Address
Phone *
Phone
Assessments *
Which tests will be administered during the event? (Not all tests are available in all states.)
Has a health screening event been held at this location(s) in the past?
Which groups of individuals will have access to the Awareness Health Screening services?
Please describe any incentives that participants will receive for completing an Awareness Health Screening.
How many individuals will be eligible to participate in this Awareness Health Screening event?
Expected Participation
How many individuals are expected to participate in your event?
How many different locations will host an Awareness Health Screening session?
How many total sessions will be included in your Awareness Health Screening event?
Start Date
Start Date
What date would you like to start your Awareness Health Screening (AHS) event?
Session 1 Details
A session is defined as a specific combination of date and location in which services will be delivered.
Session 1 Address *
Session 1 Address
Please provide the name and address for this session.
Session 1 Date *
Session 1 Date
Please provide the date of this session.
Session 1 Start Time *
Session 1 Start Time
Please provide the time employees will begin being seen for appointments at this session. (Our staff generally arrives 1 hour prior to this time for set up.)
Session 1 End Time *
Session 1 End Time
Please provide the last appointment time available for this session. (Our staff generally will leave the location 30 minutes after this time.)
Session 1 Contact Person *
Session 1 Contact Person
Who will be on site to allow entry to the location for this session?
Session 1 Phone *
Session 1 Phone
Please provide the cell phone number for this contact person so that we can reach them prior to the session start time.
Please estimate the number of participants who will receive screening services at this session.
Please describe the room or space in which the screening services will be delivered. Provide as many details as possible such as room size, layout of any fixed furniture, number of doors, etc.
Session 1 Internet Access *
Is there internet access available at this location?
Session 2 Details
Session 2 Address
Session 2 Address
Please provide the name and address for this session.
Session 2 Date
Session 2 Date
Please provide the date of this session.
Session 2 Start Time
Session 2 Start Time
Please provide the time employees will begin being seen for appointments at this session.
Session 2 End Time
Session 2 End Time
Please provide the last appointment time available for this session.
Session 2 Contact Person
Session 2 Contact Person
Who will be on site to allow entry to the location for this session?
Session 2 Phone
Session 2 Phone
Please provide the cell phone number of this contact person.
Please estimate the number of participants who will receive screening services at this session.
Please describe the room or space in which the screening services will be delivered.
Session 2 Internet Access
Is there internet access available at this location?
Session 3 Details
Session 3 Address
Session 3 Address
Session 3 Date
Session 3 Date
Session 3 Start Time
Session 3 Start Time
Session 3 End Time
Session 3 End Time
Session 3 Contact Person
Session 3 Contact Person
Session 3 Phone
Session 3 Phone
Session 3 Internet Access
Session 4 Details
Session 4 Address
Session 4 Address
Session 4 Date
Session 4 Date
Session 4 Start Time
Session 4 Start Time
Session 4 End Time
Session 4 End Time
Session 4 Contact Person
Session 4 Contact Person
Session 4 Phone
Session 4 Phone
Session 4 Internet Access
Session 5 Details
Session 5 Address
Session 5 Address
Session 5 Date
Session 5 Date
Session 5 Start Time
Session 5 Start Time
Session 5 End Time
Session 5 End Time
Session 5 Contact Person
Session 5 Contact Person
Session 5 Phone
Session 5 Phone
Session 5 Internet Access
To provide details on additional sessions, please contact us at 888-509-3020.
Health Plan Coverage *
Is your organization covered by a MVP Health Care Plan?
If you organization is covered under a MVP plan, please provide your group ID number.