Health Department Voucher for HumanaVitality Members
Height Blood Pressure
Weight Glucose Screening *
Waist Circumference Cholesterol Screening *
Individual Patient Report (member brochure)
* For the Cholesterol and Glucose Screenings, fasting 9-12 hours prior to your screening is encouraged. To the extent your health permits, no food should be consumed during this time but we
strongly encourage you to drink plenty of water.
Visit LivingWell.ky.gov or call 1.877.597.7474 to find the Local Health Department closest to you.
MANDATORY DOCUMENTS TO BRING:
1. When visiting the Health Department, please bring this Health Department Voucher along
with Photo Identification (example – Driver’s License), and Humana ID Card.
2. You will register as a patient. When prompted as to the reason for your visit, specify
“biometric Screening.” When you are seen by the healthcare provider present your voucher
and state that you are with Humana Vitality. You will NOT be required to pay for the noted
services. Humana Vitality has agreed to be billed for the noted services provided to you.
3. Please present this Voucher to the Health Department Provider at the beginning of
your visit so that we can ensure the appropriate services are performed. Health Department
Provider will collect this Voucher from you.
The Kentucky Local Health Departments are professional, preventive healthcare clinics located in each county of the Commonwealth. The mission of Public Health is to improve the health and safety of people in Kentucky through Prevention, Promotion and Protection using
education, service and innovative partnerships.
Once Screening is complete, results could take up to 45 days to appear in your Humana Vitality account.
For Kentucky Health Department Provider
Company Name: Humana Inc. Services: 80061, 82962, 99401
Promotional Code(s): HUVT Valid Dates: 1/1/2012 –
Kentucky Health Department Provider must scan this voucher into the patient record and
enter the following information for record:
; Blood Pressure
; Waist Circumference,
; Total Cholesterol - HDL, LDL, Triglycerides, Total Chol / HDL ratio
All results need to be entered into the Patient Registration and Patient Encounter along with member first
name, last name, date of birth, gender, and member ID from the member’s Humana card.
This voucher only applies to the services and promotional codes listed above. All other Health
Department services are to be charged at standard rate.
Vitality Check Consent Form
Member Name: ___________________________________ __ Member E-mail: _____________________________
Member Date of Birth: _____________________________ Phone #: _____________________________________
Humana ID number:_______________________________ Group #:_____________________________________
Primary Care Provider: ________________________________ Number in Household: _________________________ Measurements Required:
Waist Circumference Blood Pressure
Total Cholesterol Triglycerides
The _________________County Health Department has my permission to complete the screening required for HumanaVitality, Vitality Check, and my permission to forward
my information, including the screening results, to the HumanaVitality program.
Member Signature: __________________________________________________________________________
Date of Vitality Check: ______________________________________________________________________