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.
IMPORTANT
Visit must have occurred on or after May 2, 2026 to be considered or credit during the current wellness year period. Submissions received AFTER May 1, 2027 will not be counted in the 2026-2027 total.
Participant Name
*
First Name
Last Name
Participant 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
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
2 digit month, 2 digit day, 4 digit year
Date
Name of Healthcare Provider or Event
*
Healthcare Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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, lab results, visit notes, insurance claim, etc...)
*
Yes I do
No I do not
Please Upload Your File(s) Here
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If you do not have documentation to upload from your visit, please provide details about this activity to support the eligibility requirements (see handbook for eligible activities).
*
EMPLOYEE ACKNOWLEDGEMENT: 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 will lose credit for this activity and may lose eligibility in the wellness program as a result.
*
I agree
Participant Name
*
First Name
Last Name
Participant Signature
*
Wellness Credits for this activity
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