Home Insurance Wellness Discount Certification Form IB07

Wellness Discount Certification Form IB07

Wellness Discount Certification Form IB07

 

INSTRUCTIONS: ALABAMA WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

 

 

Alabama state employees who have participated in a worksite wellness screening and have since taken correctly documented steps to control identified health risks may apply for a wellness premium discount on their health insurance coverage by filing a form IB07. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Wellness Discount Certification Form IB07 Step 1: In the first blank box, enter the member name.

 

Alabama Wellness Discount Certification Form IB07 Step 2: In the second blank box, indicate with a check mark whether you are male or female.

 

Alabama Wellness Discount Certification Form IB07 Step 3: In the third blank box, enter your age.

 

Alabama Wellness Discount Certification Form IB07 Step 4: In the fourth blank box, enter your contract number.

 

Alabama Wellness Discount Certification Form IB07 Step 5: In the fifth blank box, enter your Social Security number.

 

Alabama Wellness Discount Certification Form IB07 Step 6: In the sixth blank box, enter your date of birth.

 

Alabama Wellness Discount Certification Form IB07 Step 7: In the seventh blank box, enter your daytime telephone number, including the area code.

 

Alabama Wellness Discount Certification Form IB07 Step 8: Check the first box if you were counseled by a health provider. You must attach either a wellness program office visit referral or a completed provider screening form documenting results. Indicate which with a check mark.

 

Alabama Wellness Discount Certification Form IB07 Step 9: Check the fourth box if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates on which you attended.

 

Alabama Wellness Discount Certification Form IB07 Step 10: Check the fifth box if you participated in a SEIB Fitness Center's wellness program. Enter the name and phone number of the program, the dates you attended and a program description.

 

Alabama Wellness Discount Certification Form IB07 Step 11: Check the sixth box if you self-managed your health risks. You must attach valid proof.

 

Alabama Wellness Discount Certification Form IB07 Step 12: You must submit this form to the Alabama State Employees' Insurance Board no later than November 30th. Incomplete forms will not be processed and will be returned. Mail the form to the address given at the bottom of the page.

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