2026 Wellness Exam Verification Form

Wellness Exam Verification Form To encourage a healthy relationship with a primary care physician, employees receive a Health Savings Account contribution for having received an annual physical. This form must be signed by the physician completing the exam or a physician’s office staff member. SECTION TO BE COMPLETED BY EMPLOYEE: Patient Name (Last, First, MI): DOB: Employee Name (if different): Address (Street, City, State): Email (Optional): Best Telephone #: Employer Name: Bose McKinney Evans Primary Care Doctor: Primary Care Office Phone: SECTION TO BE COMPLETED BY PHYSICIAN Date of Today’s Exam: Primary Care Doctor Signature: _______________________________ Date:________________ Please use the appropriate ICD-10 Diagnosis and CPT code that refers to Preventive Care Services. Claim should be filed to the insurance carrier indicated on the patient’s ID card. Recommended Wellness Screens are based on CDC guidelines. Note: Employees and spouses of employees who elect to have a Routine Physical Exam will receive a $250 deposit into their Health Savings Account. This form must be provided to Human Resources by November 30, 202 6 in order to receive the 202 6 Health Savings Account deposit. Form should be faxed to Cindy Morel at 317-223-0208 or emailed to CMorel@boselaw.com