Program Forms

Some Healthy Activities require you to return a form and other documentation to the Fund Office.

The table below shows the activities that require a form; you can download the form(s) you need here, or contact the Fund Office to request copies.

Healthy ActivityForm Required
Provide your and your primary doctor’s contact information to the Fund Contact Information Form
Get preventive health care services As long as you visit an in-network provider, a form shouldn’t be needed.

However, if you if you receive services from a clinic or other facility (e.g., your husband gets his flu shot at work), return the Preventive Health Care Services Form to the Fund Office
Complete a biometric health screening through your doctor’s office Physical Exam and Health Screening Form
Complete healthy lifestyle activities Healthy Lifestyle Activities Form

You also may need the Rx-HRA Option Form.  If you want to use your HRA dollars to help pay for prescription drug expenses, this form is required. You can return this form at any time during the year. But remember, the Fund cannot reimburse you retroactively for previously processed claims.