Wellness Claim Form

Wellness pictureFiling a claim for your calendar year Wellness Benefit is easy! If you have had one of the listed preventative tests or HPV Vaccination  outlined in the claim form,  please check the appropriate boxes and attach any documentation you may have that show the provider, patient’s name, the date of the test, and exam performed.   Wellness Claim Form

 

 

Filing a claim for your calendar year Wellness Benefit is easy! If you have had one of the listed preventative tests or HPV Vaccination  outlined in the claim form,  please check the appropriate boxes and attach any documentation you may have that show the provider, patient’s name, the date of the test, and exam performed.   Wellness Claim Form