• 2018-2019 Forms
    Use these forms if you are submitting for the 2018/2019 plan year.  
    Your physical occurred between July 1, 2018 and June 30, 2019
    Your wellness activity occurred and was paid for between July 1, 2018 and June 30, 2019
    • Fitness Activity Fee Reimbursement -  membership fees (gym or aquatic center) and classes
      A membership contract and/or fee schedule MUST be submitted with your proof of payment and claim form
    • Annual Physical Exam Rewards
      Language indicating the patient was seen for a preventive visit must be included on medical facility letterhead or a physician's script pad
    • Plan year is July 1, 2018 - June 30, 2019
      Deadline for submission is July 15, 2019.  Late submissions will not be accepted
    • Please read all guidelines 
    Wellness Activity Fee Reimbursement:
    Your activity reimbursement will not be processed without a contract or fee schedule from the facility.  This is required for all claims.
    2018-2019 Wellness Activity Form
    Physical Exam Reward:
    2018-2019 Annual Physical Reward



     Submit 2018/2019 forms by July 15, 2019. No exceptions; any 2018-2019 forms submitted after July 15, 2019 will not be eligible. 
    A $5 reissuance fee will be charged for re-issued checks