Page 127 - Tampa Bay Rays 2023 Flipbook

Preventative Care Verification Form

As a Rays Wellness Rewards participant, the spouse/partner of an employee may receive incentives through
maintaining a healthy lifestyle. The mandatory program requirements are listed below. If you choose not to fulfill
the mandatory requirements set forth, your spouse/partner (the employee) will be subject to a
premium surcharge in 2024.

First Name Last Name

Signature of Spouse/Partner Date

Employee’s Name

Complete RealAge Test (by visiting mycare.sharecare.com on or after 1/1/23)

Date Completed:

Complete 1 of these 2 Options

• Set a Goal with a Health Coach by calling (888) 258-3428 – Date Completed:
Or
• Complete Annual Flu Vaccine – Signature of Practitioner:

Please complete your specific area of responsibility/specialty by indicating the date of the exam or procedure,
signing your section and providing an office phone number for verification purposes. Once complete, this form
should remain with the patient. No Protected Health Information (PHI) and no results of any screenings should
be included on or attached to this form.

Physical Exam

My patient is (check one):
 Up-to-date. Date of last physical exam:

Signature of Practitioner Office #

Dental Exam or Cleaning

My patient is (check one):
 Up-to-date. Date of last dental exam:

Signature of Practitioner Office #

In order to receive credit, the mandatory program requirements listed above must all be completed
and submitted to the Human Resources department no later than 9/30/2023.