Form DCH-1315 "Health Risk Assessment" - Michigan

What Is Form DCH-1315?

This is a legal form that was released by the Michigan Department of Health and Human Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DCH-1315 by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DCH-1315 "Health Risk Assessment" - Michigan

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Health Risk Assessment
INSTRUCTIONS
The Healthy Michigan Plan is very interested in helping you get healthy and stay healthy. We want to ask you a few
questions about your current health. Your doctor and your health plan will use this information to better meet your
health needs. The information you provide in this form is personal health information protected by federal and state
law and will be kept confidential. It CANNOT be used to deny health care coverage.
We also encourage you to see your doctor for a check-up as soon as possible after you enroll with a health plan, and
at least once a year after that. An annual check-up appointment is a covered benefit of the Healthy Michigan Plan.
Contact your health plan if you need transportation assistance to get to and from this appointment.
If you need assistance with completing this form, contact your health plan. You can also call the Beneficiary Help
Line at 1-800-642-3195 or TTY 1-866-501-5656 if you have questions.
You can also learn more at this website: www.healthymichiganplan.org.
Instructions for completing this Health Risk Assessment for Healthy Michigan Plan:
Answer the questions in sections 1-3 as best you can. You are not required to answer all of the questions.
Call your doctor’s office to schedule an annual check-up appointment. Take this form with you to your
appointment.
Your doctor or other primary care provider will complete section 4. He or she will send your results to your
health plan.
Don’t forget to complete a new health risk assessment each year.
After your appointment, keep a copy or printout of this form that has your doctor’s signature on it. This is your record
that you completed your annual Health Risk Assessment.
DCH-1315 (10/18)
Page 1 of 5
Health Risk Assessment
INSTRUCTIONS
The Healthy Michigan Plan is very interested in helping you get healthy and stay healthy. We want to ask you a few
questions about your current health. Your doctor and your health plan will use this information to better meet your
health needs. The information you provide in this form is personal health information protected by federal and state
law and will be kept confidential. It CANNOT be used to deny health care coverage.
We also encourage you to see your doctor for a check-up as soon as possible after you enroll with a health plan, and
at least once a year after that. An annual check-up appointment is a covered benefit of the Healthy Michigan Plan.
Contact your health plan if you need transportation assistance to get to and from this appointment.
If you need assistance with completing this form, contact your health plan. You can also call the Beneficiary Help
Line at 1-800-642-3195 or TTY 1-866-501-5656 if you have questions.
You can also learn more at this website: www.healthymichiganplan.org.
Instructions for completing this Health Risk Assessment for Healthy Michigan Plan:
Answer the questions in sections 1-3 as best you can. You are not required to answer all of the questions.
Call your doctor’s office to schedule an annual check-up appointment. Take this form with you to your
appointment.
Your doctor or other primary care provider will complete section 4. He or she will send your results to your
health plan.
Don’t forget to complete a new health risk assessment each year.
After your appointment, keep a copy or printout of this form that has your doctor’s signature on it. This is your record
that you completed your annual Health Risk Assessment.
DCH-1315 (10/18)
Page 1 of 5
Health Risk Assessment
First Name, Middle Name, Last Name, and Suffix
Date of Birth (mm/dd/yyyy)
Mailing Address
Apartment or Lot Number
mihealth Card Number
City
State
Zip Code
Phone Number
Other Phone Number
SECTION 1 - Initial assessment questions (check one for each question)
1.
In general, how would you rate your health?
Excellent
Very Good
Good
Fair
Poor
2.
Has a doctor told you that you have hearing loss or are deaf?
Yes
No
3.
(For women only) Are you currently pregnant?
Yes
No
Not applicable (men only)
4.
In the last 7 days, how often did you exercise for at least 20 minutes in a day?
Every day
3-6 days
1-2 days
0 days
Exercise includes walking, housekeeping, jogging, weights, a sport or playing with your kids. It can be done on the job,
around the house, just for fun or as a work-out.
5.
In the last 7 days, how often did you eat 3 or more servings of fruits or vegetables in a day?
Every day
3-6 days
1-2 days
0 days
Each time you ate a fruit or vegetable counts as one serving. It can be fresh, frozen, canned, cooked or mixed with
other foods.
6.
In the last 7 days, how often did you have (5 or more for men, 4 or more for women) alcoholic drinks at one
time?
Never
Once a week
2-3 times a week
More than 3 times during the week
1 drink is 1 beer, 1 glass of wine, or 1 shot.
7.
In the last 30 days have you smoked or used tobacco?
Yes
No
If YES, Do you want to quit smoking or using tobacco?
Yes
I am working on quitting or cutting back right now
No
8.
How often is stress a problem for you in handling everyday things such as your health, money, work, or
relationships with family and friends?
Almost every day
Sometimes
Rarely
Never
DCH-1315 (10/18)
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Health Risk Assessment
First Name, Middle Name, Last Name, and Suffix
mihealth Card Number
9.
Do you use drugs or medications (other than exactly as prescribed for you) which affect your mood or
help you to relax?
Almost every day
Sometimes
Rarely
Never
This includes illegal or street drugs and medications from a doctor or drug store if you are taking them differently than
exactly how your doctor told you to take them.
10. Have you had a flu shot in the last year?
Yes
No
11. How long has it been since you last visited a dentist or dental clinic for any reason?
Never
Within the last year
Between 1-2 years
Between 3-5 years
More than 5 years
12. Do you have access to transportation for medical appointments?
Yes
No
Sometimes, but it is not reliable
Transportation could be your own car, a friend who drives you, a bus pass, or taxi. Your health plan can help you with a
ride to and from medical appointments.
13. Do you need help with food, clothing, utilities, or housing?
Yes
No
This could be trouble paying your heating bill, no working refrigerator, or no permanent place to live.
14. A checkup is a visit to a doctor’s office that is NOT for a specific problem. How long has it been since
your last checkup?
Within the last year
Between 1-3 years
More than 3 years
SECTION 2 - Annual appointment
A routine checkup is an important part of taking care of your health. An annual check-up appointment is a covered
benefit of the Healthy Michigan Plan and your health plan can help you with a ride to and from this appointment.
Date of appointment:
(mm/dd/yyyy)
At my appointment, I would most like to talk with my doctor about:
An annual appointment gives you a chance to talk to your doctor and ask any questions you may have about your
health including questions about medications or tests you might need.
Take this form to your check-up and complete the rest of the form with your doctor at this
.
appointment
DCH-1315 (10/18)
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Health Risk Assessment
First Name, Middle Name, Last Name, and Suffix
mihealth Card Number
Section 3 - Readiness to change
Your Healthy Behavior
Small everyday changes can have a big impact on your health. Think about the changes you would be most interested
in making over the next year. It is also important to get any health screenings recommended by your doctor.
Now that you have thought about your healthy behavior, answer questions 1 - 3. For each question, use the scale
provided and pick a number from 0 through 5.
1.
Thinking about your healthy
behavior, do you want to
0
1
2
3
4
5
make some small lifestyle
I don’t want to make
I want to learn more about
Yes, I know the changes I
changes in this area to
changes now
changes I can make
want to start making
improve your health?
2.
How much support do you
think you would get from
0
1
2
3
4
5
family or friends if they
I don’t think family or
I think I have some support
Yes, I think family or
knew you were trying to
friends would help me
friends would help me
make some changes?
3.
How much support would
you like from your doctor or
0
1
2
3
4
5
your health plan to make
I do not want to be
I want to learn more about
Yes, I am interested in
these changes?
contacted
programs that can help me
signing up for programs
that can help me
Section 4 – To be completed by your primary care provider
Primary care providers should fill out this form for Healthy Michigan Plan beneficiaries enrolled in Managed Care Plans
only. Fill in the “Healthy Behaviors Goals Progress” question and select a “Healthy Behavior Goals” statement in
discussion with your patient. Sign the Primary Care Provider Attestation, including the date of the appointment. Both
parts of Section 4 must be filled in for the attestation to be considered complete.
Healthy Behaviors Goals Progress
Did the patient maintain or achieve/make significant progress towards their selected health behavior goal(s)
over the last year?
Not applicable – this is the first known Healthy Michigan Plan Health Risk Assessment for this patient.
Yes
No
Patient had a serious medical, behavioral, or social condition or conditions which precluded addressing unhealthy
behaviors.
DCH-1315 (10/18)
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Health Risk Assessment
First Name, Middle Name, Last Name, and Suffix
mihealth Card Number
Healthy Behavior Goals
Choose one of the following for the next year:
1. Patient does not have health risk behaviors that need to be addressed at this time.
2. Patient has identified at least one behavior to address over the next year to improve their health
(choose one or more below):
Increase physical activity, learn more about nutrition
Reduce/quit alcohol consumption
and improve diet, and/or weight loss
Reduce/quit tobacco use
Treatment for substance use disorder
Annual influenza vaccine
Dental visit
Follow-up appointment for screening or
Follow-up appointment for maternity
management (if necessary) of hypertension,
care/reproductive health
cholesterol and/or diabetes
Follow-up appointment for recommended cancer or
Follow-up appointment for mental
other preventative screening(s)
health/behavioral health
Other: explain
3. Patient has a serious medical, behavioral or social condition(s) which precludes addressing unhealthy behaviors
at this time.
4. Unhealthy behaviors have been identified, patient’s readiness to change has been assessed, and patient is not
ready to make changes at this time.
5. Patient has committed to maintain their previously achieved Healthy Behavior Goal(s).
Primary Care Provider Attestation
I certify that I have examined the patient named above and the information is complete and accurate to the best of my
knowledge. I have provided a copy of this Health Risk Assessment to the member listed above.
Provider Last Name
Provider First Name
National Provider Identifier (NPI)
Provider Telephone Number
Date of Appointment
Signature
Date
Submit form by fax or via CHAMPS:
Fax to:
517-763-0200
CHAMPS: The Health Risk Assessment form can be submitted and viewed in the CHAMPS system via the Health Risk
Assessment Questionnaire Web Page.
The Michigan Department of Health and Human Services does not discriminate against any individual or group because of race, religion, age, national
origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs, or disability.
AUTHORITY: MCL 400.105(d)(1)(e)
COMPLETION: Is voluntary, but required for participation in certain Healthy
Michigan Plan programs.
DCH-1315 (10/18)
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