To obtain a 2017 Physician Screening Form, please complete the fields below and click submit.
 
All fields are required.
 
For questions about the 2017 Physician Screening Form, or login assistance please contact Healthways Customer Support at (888) 616-6411.
First Name:
You may need to enter your first name and middle name with a space between them
Last Name:
Date of Birth: (mm/dd/yyyy)
Zip Code:
Gender: