Completed physician form is due on or before August 31, 2020. Date of test must be on or after October 1, 2019.
Before you submit your form:
• Step 1: Complete top section of form, including your name, date of birth and contact information.
• Step 2: Ensure that you have signed the form. Without your signature, this form will not be accepted.
• Step 3: Your physician’s office should provide your most recent lab and biometric results and the date of testing.
• Step 4: Scan and upload here. It is recommended that you send your form directly, rather than asking your physician office to send.
You will receive a confirmation email from US Wellness when your form is received and reviewed. If you do not receive an email confirmation within two business days or if you have questions regarding your form, please call US Wellness at 888-926-6099 x900. If you are not able to participate in a screening or complete the HRA due to a medical reason, please contact US Wellness at 888-926-6099 x900.
The uploader is not available at this time.