Page 29 - CPS Benefits Guide
P. 29
Wellness Certification
Wellness exams must be completed within 30 days of your coverage effective date for eligible discounts.
Patient’s name
Date wellness/physical examination completed
If patient is the spouse of employee please provide
(employee’s name)
Physician’s name
Phone number
Address
City, state, ZIP
Physician’s signature
Note: This certiication form or explanation of beneits along with your online health assessment (myuhc.com)
must be completed to be eligible for your 2016 wellness discount. Please do not send protected health
information (PHI).
Employee signature
Valid email address to email conirmation receipt
Please return this completed form to beneits@cpspharm.com or 901.748.0469 via fax.
Comprehensive Pharmacy Services 29
Wellness exams must be completed within 30 days of your coverage effective date for eligible discounts.
Patient’s name
Date wellness/physical examination completed
If patient is the spouse of employee please provide
(employee’s name)
Physician’s name
Phone number
Address
City, state, ZIP
Physician’s signature
Note: This certiication form or explanation of beneits along with your online health assessment (myuhc.com)
must be completed to be eligible for your 2016 wellness discount. Please do not send protected health
information (PHI).
Employee signature
Valid email address to email conirmation receipt
Please return this completed form to beneits@cpspharm.com or 901.748.0469 via fax.
Comprehensive Pharmacy Services 29
