Incentive Program
2024 Provider Verification Form NOTICE TO PATIENT Please fill out the top portion of this form and take it to your medical provider when you complete your preventive screening/exam or qualifying wellness activity. This activity must occur between [INSERT DATES] to count towards the [COMPANY NAME] Incentive Program activities. Once completed by your provider, it is YOUR responsibility to submit this form to the contact information below. BY COMPLETING THIS FORM AND SUBMITTING IT TO [COMPANY NAME], YOU CONSENT TO THE DISCLOSURE TO [COMPANY NAME] THAT YOU HAVE COMPLETED THE ACTIVITIES DESCRIBED BELOW. You may revoke your consent to this disclosure at any time by sending us a notice in writing. Your revocation will not apply to information already disclosed by [COMPANY NAME] pursuant to this verification form.
TODAY’S DATE PATIENT NAME (Please Print Clearly)
PATIENT DATE OF BIRTH
If SPOUSE, PLEASE PROVIDE EMPLOYEE NAME (Please Print Clearly) EMPLOYEE DATE OF BIRTH
NOTICE TO PROVIDER Your patient has an opportunity to complete preventive screenings/exams or other health and wellness activities as a part of their employer or group health plan’s wellness incentive program. Please complete the section below to verify that you have provided services to this patient.
2024 Incentive Program Qualifying Activities Program Activity
Activity Date
Provider Signature
Colonoscopy/Colon Cancer Screening Dental Cleaning/Exam Mammogram Prostate Exam Vision (Eye) Exam Well-Woman Exam Flu Shot PROVIDER NAME (PRINT OR PROVIDER STAMP)
DEADLINES: Please fax, email, or mail this form to [COMPANY NAME] using the information below. You must submit this form no later than [INSERT DATE] COMPANY NAME
PROVIDER PHONE NUMBER
ADDRESS EMAIL