Get Il Calhoun District 40 Missvic Wellness Initiative Physician Verification Form 2017-2025

This guide provides step-by-step instructions for completing the IL Calhoun District 40 MissVIC Wellness Initiative Physician Verification Form online. Follow these instructions carefully to ensure your submission is accurate and complete.

Follow the steps to successfully complete the physician verification form.

1. Click the ‘Get Form’ button to access the verification form. It will open for you to fill out online.
2. In the first section, fill in the participant’s name clearly in the designated field. This must be their printed name.
3. Provide the participant’s employer name in the corresponding field to ensure accurate identification.
4. Enter the participant’s contact email address, followed by their phone number. Ensure the email is accurate for any correspondence.
5. Input the participant’s date of birth and today’s date in the relevant fields using the format MM/DD/YYYY.
6. Confirm that the annual wellness exam took place between July 1, 2017, and June 30, 2018, as this is a requirement for program participation.
7. The licensed medical professional should fill in their printed name, phone number, and address accurately to verify the exam.
8. The medical professional must sign the form where indicated and include their license number in the provided field.
9. Enter the exam date in the appropriate fields, formatted as MM/DD/YYYY.
10. Finally, choose one of the submission methods available: scan and email the form, send via secure fax, or mail the physical form to the provided address.
11. After filling out all fields, review the details to ensure accuracy before submitting the form.

Complete your form online today to streamline your participation in the wellness initiative.