Page 128 - Tampa Bay Rays 2022 Flipbook

Preventative Care Verification Form

As a Rays Wellness Rewards participant, 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, you will be subject to a premium surcharge in 2023.

First Name_____________________________ Last Name ______________________________

Signature of Employee______________________ Date_________________

Complete RealAge Test (by visiting mycare.sharecare.com on or after 1/1/22)
Date Completed: _______________

Complete Your Biometrics Screening
 Offered onsite or via lab voucher https://portal.ichtools.com

Complete 1 of these 3 Options
 Set a Goal with a Health Coach by calling (888) 258-3428 – Date Completed:_____________
Or
 Complete Annual Flu Vaccine – Signature of Practitioner:_________________________________
Or
 Complete Preventative Screening (mammogram, cervical screening, or colorectal screening)
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 6/30/2022.