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Virgin Pulse Health Care Provider Form


As part of the Healthy YOU program, you may submit screening results from your physician by sending your completed form to Virgin Pulse. Once the results are loaded into the system, you will receive 1,000 points for submitting your screening data. Points will be credited to your account the month following receipt of the form by Virgin Pulse.

Completed by Participant

Last Name:

First Name:

Male:

Female:

Employee:

Date of Birth:

.

.

(MM)

(DD)

(YYYY)

Consent to Use Information. I, Participant, hereby authorize my provider to release any information within this form to my wellness program, Virgin Pulse, Inc. I understand that Virgin Pulse, Inc. will utilize this information solely for the purposes of administration of its wellness program and will dispose of this form in accordance with any applicable law.

I certify that the information supplied on this form has been provided to me by my health care provider, and I understand that Virgin Pulse may contact my health care provider listed on this form with questions regarding my information.

Completed by Health Care Provider or Participant

Date of Exam: _________________ Health Care Provider Name: __________________________________________________
NPI#______________________

Requirements:Phone: _________________________________
Complete this form in full. Incomplete or late submissions of this form may delay or eliminate your patient / employee from incentive eligibility. Submit this form using one of the following methods: Fax to 508-302-0055 or Scan and E-mail to forms@virginpulse.com

I hereby certify that I have not used any cigarettes, cigars, pipes, snuff, chewing tobacco, nicotine gum or other tobacco or nicotine delivery system in the last 6 months (mark one below).

Agree

Disagree

By signing this form, I certify the following: I have truthfully checked the Agree or Disagree box that accurately reflects my use of tobacco/nicotine and I understand that tobacco products include cigarettes, cigars, chewing or pipe tobacco, nicotine gum or any other tobacco or nicotine products regardless of the frequency or method of use.

Signature ____________________________________________ Print Name ___________________________________

Date _________________________

*Allow 7 business days for processing

Questions? Call Virgin Pulse support at 1(888)-671-9395

Please reference your sponsor ID 2891303 when calling.