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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How to fill out the 14-jpmorganchasehsr1 online
The 14-jpmorganchasehsr1 form is essential for JPMorgan Chase employees and their covered partners to report wellness screening results to health care providers. This guide will provide clear and systematic instructions on how to complete this form effectively and ensure compliance with the submission timelines.
Follow the steps to successfully complete the 14-jpmorganchasehsr1 form.
- Click the ‘Get Form’ button to access the document and open it in your preferred editor.
- Complete Section 1 as the participant. Enter your name, including your first name, middle initial, and last name accurately. If applicable, list the name of the JPMorgan Chase employee if you are their covered spouse or domestic partner. Provide your age and date of birth, followed by your email address.
- Indicate your gender by selecting either 'Male' or 'Female'. Specify your status by choosing either 'Employee' or 'Spouse/Domestic Partner'. Then, fill in your Employee Standard ID and phone number.
- Sign and date the designated section to give your healthcare provider permission to fax the completed form to Provant Health Solutions. Be aware that the form should be submitted within 31 days of your wellness screening date.
- Proceed to Section 2 for completion by your healthcare provider. They should mark whether the screening was fasting or non-fasting and fill in the relevant health metrics like total cholesterol, glucose, blood pressure, height, weight, and body mass index.
- Your healthcare provider must print their name and sign the section, along with the date of completion. If available, ensure that they apply an office stamp for added identification.
- After both sections of the form are completed, ensure that it is faxed or emailed to the address provided within the specified timeframe. You may also choose to save, download, or print the completed form for your records.
Complete your 14-jpmorganchasehsr1 form online today to ensure timely submission and eligibility for wellness rewards.
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