Get Verification Of Wellness Examination Formv4a Fund Mailing Info

This guide provides clear and supportive instructions on how to fill out the Verification Of Wellness Examination Form V4a Fund Mailing Info online. Follow these steps to ensure that all necessary information is accurately entered and submitted.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to access the Verification Of Wellness Examination Form V4a Fund Mailing Info and open it in your editor.
2. Begin by completing Section 1, designated for the employee, non-Medicare retiree, or surviving spouse. Indicate your status by checking the appropriate box — either 'Active Employee' or 'Non-Medicare Retiree or Surviving Spouse.'
3. Fill in your personal details: last name, first name, middle initial, date of birth (in the format mm/dd/yyyy), ArcelorMittal location or plant, and your insurance card ID number.
4. Provide your contact information by entering your phone number in the designated field.
5. Specify for whom the verification is being completed by checking the relevant box: 'Employee/Retiree or Surviving Spouse' or 'Spouse covered under my ArcelorMittal Healthcare Plan.'
6. If the verification form is for your spouse, complete their details as follows: last name, first name, middle initial, and date of birth (in the format mm/dd/yyyy).
7. Ensure you sign and date the form in the designated signature fields. If applicable, your spouse should also do the same.
8. Proceed to Section 2, to be completed by the healthcare provider. This section requires the date of service and a confirmation that the patient was seen.
9. The healthcare provider should check off the examinations that were completed during the visit, including height, weight, blood pressure, and discussions of recommended exams.
10. The healthcare provider must provide their name, phone number, and signature along with the date signed.
11. If the healthcare provider has an office stamp, it should be applied in the specified area on the form.
12. Finally, review all entered information for accuracy. Once confirmed, save any changes, download, print, or share the completed form as required.

Complete your Verification Of Wellness Examination Form online today for a seamless submission process.