Healthcare Incentive Verification Form
Please complete the following fields to verify your eligibility for the healthcare incentive. Do not enter sensitive health or financial information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Employer Name
*
Program Reference Suffix (last 4 characters)
*
Type of Healthcare Incentive
*
Please Select
Wellness Program
Annual Health Screening
Vaccination Bonus
Fitness Challenge
Other
Date of Participation or Completion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Eligibility Status
*
Eligible
Not Eligible
Pending Review
Please describe your participation or qualifying activity
*
Upload proof of participation (optional)
Upload a File
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of
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