Page 129 - Tampa Bay Rays 2022 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 2023.

First Name_____________________________ Last Name ______________________________

Signature of Spouse/Partner______________________ Date_________________

Employee’s Name___________________________

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

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 6/30/2022.