Get 2014 Health Risk Premium Exemption Form - Livewell

Filling out the 2014 Health Risk Premium Exemption Form for the Livewell program can be straightforward if you follow the correct procedures. This guide provides a step-by-step approach to ensure that you accurately complete the form online.

Follow the steps to fill out the form accurately and efficiently.

1. Use the 'Get Form' button to access the 2014 Health Risk Premium Exemption Form. Ensure you have a reliable internet connection to open and review the document easily.
2. In Section A, carefully input the participant's name and the employee’s Social Security Number (SSN) or employee ID number. For spouses or domestic partners, use the TeamHealth employee’s SSN.
3. Provide the email address of the participant and select the appropriate checkbox to indicate the relationship (Employee, Spouse, or Domestic Partner).
4. Enter the date of birth in the specified format and the employee ID number if applicable.
5. Indicate the gender by selecting either Female or Male, ensuring the correct choice is made.
6. Review the wellness goals section. Confirm that all five wellness goals have been met. If you haven’t met all five goals, remember to complete a health risk assessment at myuhc.com.
7. In Section B, if applicable, have a healthcare clinician complete and sign this section, or attach the necessary screening results. Ensure the values meet the acceptable health measurement benchmarks provided.
8. Read the privacy statement carefully and ensure you understand the implications of disclosing your health information. Make sure to certify that all information you have provided is accurate.
9. Sign and date the form in the designated areas. If a clinician is involved, they should also print their name, sign, and provide their phone number.
10. After completing the form, save your changes, then download, print, or share the form as necessary. Follow the instructions to fax or email the completed document to the relevant parties.

Get started on your 2014 Health Risk Premium Exemption Form online today!