Verification Forms

2023-2024 Forms

 

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

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 Annual Vision Examination Verification Form

NTIC Cervical Cancer Screening Verification Form

NTIC Colonoscopy Examination Verification Form

NTIC Dental Examination Verification Form

NTIC Dermatology Examination Verification Form

NTIC Flu Shot Verification Form

NTIC Health Screening Verification Form

NTIC Mammogram Screening Verification Form

NTIC Participant Referral Form

NTIC Primary Care Provider Verification Form

NTIC Prostate Screening Verification Form