Wellness evaluation form 2026

1. Click ‘Get Form’ to open the wellness evaluation form in the editor.
2. 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.
3. Next, provide the Provider Information. The provider should fill in their name, ID number, and phone number accurately.
4. 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.
5. 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.
6. Finally, submit the completed form within 180 days of your effective date through our platform for processing.

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