Verification Forms

2025-2026 Forms

Please complete the forms, if applicable, and UPLOAD TO YOUR HEALTH ADVOCATE PORTAL.

Forms are no longer needed for cancer screenings (cervical, prostate, mammogram, skin, etc.), dental, vision, and immunizations. Follow the instructions below and enter the date of your appointment.

To do so, from your Health Advocate account home page: Well-Being -> Rewards -> Scroll down until you find the appropriate activity -> Select the ‘Go to…’ button and upload the corresponding document.

*Accepted documents: NTIC Verification Forms, After-Visit Summary, Receipt, Dr. Note, UPMC Health Screening Results Form, Screenshot of Medical Portal.

NTIC Annual Physical Examination Verification Form

NTIC Health Screening – Bloodwork Verification Form 

NTIC Participant Referral Form

NTIC Primary Care Provider Verification Form

Healthy Outcomes

Meet 3 out of the 4 healthy outcomes – Cholesterol (200 or less or HDL/Total ratio <4.5), Triglycerides (150 or less), Blood Pressure (130/80 or less), and Fasting Glucose (100 or less).
If you have your screening done through the district and meet these outcomes, your points will be added. If you have your bloodwork done through your physician, please email Miranda Kelley <mkelley@iu17.org> your results or the form below to be granted the 75 points.

NTIC Annual Healthy Outcomes Verification Form

If you do not meet the requirements, you can still earn the 75 points by showing improvements in your bloodwork (all bloodwork must be completed during the current wellness year [June 1-May 31]), or complete 3 healthy coaching sessions either with Miranda Kelley <mkelley@iu17.org> or through the EAP (theeap.com).