Sentara Health Plans

Form

First Name*

Last Name*

Phone Number*

Email Address*

Date of Birth*

Birth Month

Birth Day

Birth Year

Were you able to complete the fall risk assessment?* Yes No

If yes, what was your fall risk assessment score?

Fall Risk Assessment Score

Would you like to be evaluated for a Personal Emergency Response System (PERS)?* Yes No

What is your preferred method of communication?* Phone Email

The fall assessment was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall risk self-assessment tool (Rubenstein et al. J Safety Res; 2011: 42(6)493-499). Adapted with permission of the authors.

¹Source: cdc.gov
²Rewards available for these visits/screenings. Rewards are not available on the Sentara Health Plans Medicare Savings (HMO) plan.
³This benefit is not available on the Sentara Health Plans Medicare Savings (HMO) plan.
⁴There may be costs associated with this service.

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© Sentara Health Plans 2026, 1300 Sentara Park, Virginia Beach, VA 23464

Sentara Health Plans is the trade name for Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., and Sentara Behavioral Health Services, Inc. Health Maintenance Organization (HMO) products, and Point-of-Service (POS) products are issued and underwritten by Sentara Health Plans. Preferred Provider Organization (PPO) products are issued and underwritten by Sentara Health Insurance Company. Sentara Health Administration, Inc. provides administrative services to group and individual health plans but does not underwrite benefits. All plans have benefit exclusions and limitations and terms under which the policy may be continued in force or discontinued. Medicare products are administered under an agreement with Sentara Health Plans and the Centers for Medicare and Medicaid Services (CMS). Medicaid and FAMIS products are administered under an agreement with Sentara Health Plans and the Virginia Department of Medical Assistance Services (DMAS).

Fall Prevention - Contact Me