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Pregnancy Confirmation Form
Follow these steps to receive credit for your participation in the 2018 Wellness Rewards Program:
1. Please print all requested information clearly.
2. Both sections MUST be fully completed and signed. Forms with information missing will be
returned for correction, which will delay Wellness Rewards credit.
3. Return the completed and signed form to your onsite WellNurse by November 30, 2017.
Note: Participants may also fax the completed and signed form to 855-816-3504.

Section 1 - to be completed by participant: PARTICIPANT INFORMATION
First Name:

Relationship:



Employee



Last Name:

Employee ID Number (or Medical Plan ID Number):

Date of Birth:

Property/Location Code:

Phone Number:

(

Spouse

Address:

)

City, State, ZIP:

Email Address:

Participant Signature:

Date:

Section 2 - to be completed by the provider of the service:
PREGNANCY CONFIRMATION FORM - Complete and Return Form by 11/30/2017
Note to Provider: Your patient is participating