2019-2020 Wellness Your Way Program

Checklist

Instructions: Please use this checklist to verify that you have completed the components to receive your 2020-2021 incentive. The qualifying period for submission is June 1, 2019 to May 31, 2020. Please print clearly on all forms and keep a copy of all forms for your own records. Keep this checklist for your records.

COVID-19 DATE REVISION: Complete your Annual Physical Exam and Lab Work by December 31, 2020. Once forms are received and credited, retroactive payment will be issued dating back to July 2020. Please note that Step 2, as outlined below, is still required to be completed and submitted no later than May 31, 2020. Employees who do not complete/submit Step 2 will NOT be eligible for the Annual Physical Exam and Lab Work extension.

Incentive Qualifier Instructions & Documentation Required to Earn Incentive

Required: Complete the components below.

Complete an Annual Physical Exam and Lab Work

Submit Healthcare Provider Verification Form completed and signed by physician or healthcare provider to Wellness Council of Arizona.

Required: Pick 1 out of 6 options below. You must complete this Required portion no later than May 31, 2020.

Option 1: Complete and sign the Non-Tobacco User Affidavit Form.

Submit the Non-Tobacco User Affidavit Form to the Wellness Council of Arizona.

Option 2: Attend 3 Wellness Presentations (Webinar or In-Person) with Health Coach.

In-Person: Be sure to sign in with the Health Coach Webinar: Register with your email address

Option 3: Participate in 3 Health Coaching Sessions

Health Coach will submit records

Option 4: Submit receipts of payment for gym memberships, fitness facility or program, or home use fitness accessories.

Submit gym receipts or payment transactions with your name, email, and name of gym present.

Option 5: Submit proof of participation in fund raising fitness activities (walks, rides and runs that benefit local or national non-profits).

Provide proof of participation with copies of receipt, certificate of completion, etc. to the Wellness Council of Arizona.

Option 6: Completed 2 Wellness Challenges (List Challenges)

Health Coach will submit records

How to Submit Forms to the Wellness Council of Arizona: Secure Email: verified@welcoaz.org (preferred method)

Mailing Address: Wellness Council of Arizona, 1670 N. Kolb Rd. Ste. 246, Tucson, AZ 85715

Secure Fax Number: 520-293-3368 (follow up with a call to 520-293-3369 or email to confirm receipt of your fax)

HR Dropbox

Questions? Contact the Wellness Council of Arizona at

(520) 293-3369 Verified@welcoaz.org

To be completed by Welcoaz Staff:

Date Received Receipt Type

Date Confirmed Date Entered into Tracker

How to Submit Forms to the Wellness Council of Arizona: Secure Email: verified@welcoaz.org (preferred method)

Mailing Address: Wellness Council of Arizona 1670 N. Kolb Rd. Ste. 246, Tucson, AZ 85715

Secure Fax Number: 520-293-3368 (follow up with a call to 520-293-3369 or email to confirm receipt of your fax)

2019-2020 Wellness Your Way Program Healthcare Provider Verification Form Verified by WELCOAZ Program

Instructions: The qualifying period for submission is June 1, 2019 to December 31, 2020. Complete top field of this form and have a healthcare provider complete the bottom portion and submit a copy to the Wellness Council of Arizona. Please print clearly and keep a copy of all forms for your own records.

To be filled out by the Participant:

Participant Name Employee ID #

Gender Date of Birth Location

Male Female __ __ / __ __ / __ __ __ __

Phone Number Email

Authorization to Release Medical Information I do hereby authorize the release of the following personal health information to the Wellness Council of Arizona for the purpose of confirming eligibility to receive my wellness incentive.

Participant Signature Date

Your PHI (personal health information) is protected under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and will be kept secure by the Wellness Council of Arizona. The Wellness Council will notify your employer when you have completed this component satisfactorily. Your employer will not have access to your legally protected health information. The Wellness Council will act as the confidential record keeper of the Health & Wellness Incentive Program on behalf of your employer.

To be filled out by the Physician or Healthcare Provider:

Date Participant Underwent their Complete

Physical Exam

with Primary Care Physician

Date Participant Underwent their Complete

Lab Results

___ ___ / ___ ___ / ___ ___ ___ ___ ___ ___ / ___ ___ / ___ ___ ___ ___

Physician/ Healthcare Provider Printed Name and Signature – REQUIRED Date Phone Number