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Wellness evaluation form 2026
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- Click ‘Get Form’ to open the wellness evaluation form in the editor.
- Begin by completing Section I: Member/Provider Information. Fill in your last name, first name, date of birth, and member ID number. Ensure all fields are printed clearly.
- Next, provide the Provider Information. The provider should fill in their name, ID number, and phone number accurately.
- Move to Section II: Health Measures. This section must be completed by your provider. They will assess tobacco use, blood pressure, cholesterol levels, weight, flu shot status, and necessary immunizations.
- Once all sections are filled out, both you and your provider need to sign and date the form at the bottom to certify its accuracy.
- Finally, submit the completed form within 180 days of your effective date through our platform for processing.
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Related links
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