Voucher Request Form

Voucher Request Form
Requesting Employee Email Address
Client/Customer Contact Information

Please include all (email, phone, mailing address) contact information for the person and organization who will receive the voucher(s).
Enter Contact Information Below:*
Method of delivery for voucher(s)*

MailEmail
If you selected "mail" for the delivery method, how many vouchers do you need mailed?
What type of voucher do you need?*

Corporate Voucher (Corporate Client Requests Voucher for WHF Services)Redraw Voucher (Test Not Performed, Quantity Not Sufficient, Critical Levels, Tube Not Drawn/Missing Tube)Comp/Appreciation Voucher (Any screening given as a gift)

Corporate Voucher
Corporate clients may request vouchers for WHF screening profiles and/or products allowing their participants to attend any WHF event. Always verify bundle components prior to requesting vouchers.

Make certain the Bundle name and Location, (if appropriate) are selected as it directly affects billing.
Name of corporate bundle. (Example: State of WY Spouse bundle is Cigna-Dependent.)

Redraw Voucher
Customers may need a redraw for a variety of reasons. Please specify.

Test Not Performed (TNP)Quantity Not Sufficient (QNS)Critical LevelsTube Not Drawn/Missing TubeQuality ControlOther

We Thank You!
Please click 'Submit' to complete your request. Contact Communications Team with any further questions or follow-up.
Should be Empty:

Client/Customer Contact Information