To obtain a Physician Form, please complete the fields below and click submit.

Please enter your complete name as listed in the OAKS system. Abbreviated and/or nicknames will not be recognized.

All fields are required.

Completed forms can be mailed, fax & uploaded. New fax number: 614-448-9922

Please ensure you download and submit a new form for this program year. Forms from previous years cannot be processed.

First Name
Last Name
DOB (mm/dd/yyyy)
Zip Code (from your home address)
Gender
 




For questions about the Physician Screening Form, please contact Healthways Customer Support at (866) 556-2288.