Get 2020 Wellness Option Exam Affidavit Form

The 2020 Wellness Option Exam Affidavit Form is essential for employees seeking a premium reduction through participation in wellness activities. This guide provides clear, step-by-step instructions to help you complete the form efficiently, ensuring you understand each section involved in this process.

Follow the steps to complete your affidavit form online.

1. Press the 'Get Form' button to retrieve the affidavit form and open it in your preferred editor.
2. Begin by entering the patient information. Fill in the first and last name, along with the date of birth in the designated fields.
3. Select the type of annual preventative exam conducted by checking the appropriate box: Physical Exam, Dental Exam, or Vision Exam. Note that the dates accepted for these exams are from August 1, 2019, to October 15, 2020.
4. Proceed to the facility information section, where you must confirm the patient's visit. Enter the name of the practice, the date of their visit, and the name of the physician or authorized representative.
5. Ensure the printed name is filled in and include the date when the form is signed.
6. Once all sections are completed, review the form for accuracy. Save your changes to the document.
7. Finally, you can choose to scan the completed form and email it to bcscwellness@crh.org, fax it to BCSC Health Center at 812-375-8879, or drop it off at the BCSC Health Center.

Complete your 2020 Wellness Option Exam Affidavit Form online today to enjoy your premium reduction!