Verification Forms

2024-2025 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 flu shots. Follow the instructions below and enter the date you had the appointment.

To do so, from your Health Advocate account home page: Well-Being -> Rewards -> Scroll down until you find the appropriate activity -> Select the ‘Upload’ 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.

VERIFICATION FORMS WILL NO LONGER BE SENT TO THE WELLNESS COORDINATOR.

NTIC Annual Physical Examination Verification Form

NTIC Health Screening Verification Form

NTIC Participant Referral Form

NTIC Primary Care Provider Verification Form