Form online 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Policyholder/Patient’s Information section. Enter your name, email address, and policy number accurately to avoid processing delays.
3. In the Health Screening Information section, select the health screening test you have performed from the provided options. Ensure you include the date of the test.
4. Complete the Physician Information section with your physician's details, including their name and contact information.
5. Review all entered information for accuracy. Check any necessary boxes, such as if you are filing for a wellness benefit under multiple coverages.
6. Sign and date the form in the Authorization section to confirm that all information is correct and authorize disclosure of your health information.

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