Provide Contact Information Health Risk Questionnaire Review the Online Learning Presentation Annual Physical Preventive Health Care Services Health Screening Lifestyle Activities

Provide Contact Information (Yours and Your Primary Doctor’s)

How to

Provide the following information by returning the Contact Information Form to the Fund Office.

Your Contact InformationYour Primary Doctor’s Information
  • Home mailing address
  • Phone number (home and/or mobile)
  • Email address (if you have one)
  • Name
  • Office mailing address
  • Office phone number

What you earn

  • Gold/Silver Participants: The Fund contributes $125 to your HRA.
  • Platinum Plus/Platinum Participants: The Fund contributes $150 to your HRA.

Remember, you can earn up to the maximum allowed in one year.

Get the form

You can get a copy of the Contact Information Form or call the Fund Office to request one.