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Wellness Screening. This form must be faxed or emailed to the address indicated within 31 days of the screening date. Participant: Please fill out and sign Section 1. All information is required to process this form. It is your responsibility to ensure that your healthcare provider submits all required information within the requested timing to Provant Health Solutions. Healthcare Provider: Please fill out and sign Section 2 and fax within 31 days of the screening date to Provant Health Solutio.

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