Submit Your Wellness Activity
Qualifying activities include preventive visits and screenings only. Visits for illness or patient procedures are not preventive and will not qualify for wellness credits.
Participant Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Type of Activity
*
Please Select
Annual Physical / Check-Up
Dentist Cleaning / Xrays
Vision Screening
Hearing Screening
Colonoscopy
Mammogram
Well Woman Exam / Pap Smear
Bone Density / DEXA Scan
Specialist Check-Up / Preventive
Gym Membership/Exercise Routine
Independent/Community Event (ex: Lifestyle Challenge/5K/10K/Nutrition Challenge)
Annual Immunization
If you have more than one appointment to report for an activity (such as 2 dental cleanings or 2 different immunizations, you will need to submit a separate form for each.
Date of Visit
*
-
Month
-
Day
Year
Date
Name of Provider or Event
*
Provider Phone Number
Please enter a valid phone number.
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Wellness Activity Documentation
Please upload any documentation that supports this wellness activity
Do you have documentation to provide for this wellness activity? (an example: a doctor summary, visit notes, insurance claim, etc...)
*
Yes I do
No I do not
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If you do not have documentation, what details can you provide about that will help the wellness coach/coordinator better understand your activity?
I understand that the information and/or documentation that I am providing today is accurate and is being used for my individual wellness program eligibility only. I understand that this information and/or documentation will never be shared with my employer for any reason. I also understand that if I fail to provide documentation of this activity, or have been found to have provided false information, I risk losing credits for this activity and may lose eligibility in the wellness program as a result.
*
I agree
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