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pf09-031
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5/29/2014 11:29:01 AM
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Planning Files
Planning Files - Planning File #
09-031
Planning Files - Type
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Cih' of <br />. j`1 <br />`/.y,, <br />Minnesota, USA <br />EMPLOYEE NAME <br />Benefits Plan Contribution Incentive <br />Earn $10 a month toward your health insurance. Complete items A, B, and C below and submit a copy of this <br />form with your benefits enrollment for the New Year. Note that the physical exam/screening (item A) is required <br />on a schedule determined by your physician, whereas the blood pressure screening (item B) and Health Risk <br />Assessment (item C) need to be completed at least once a year. <br />A. Physical Exams/Screenings as appropriate for your gender, age, and personal risk factors as <br />performed by a physician and/or other qualified medical professional are required at the intervals <br />recommended for you by your physician. Based on your physician's recommendation, a physical <br />exam/screening might include blood sugar or cholesterol testing, colorectal cancer screening, <br />mammogram, obesity screening, tobacco use/exposure screening, calcium/osteoporosis counseling, <br />alcohol abuse screening, depression screening, cervical cancer screening/pap smear, and/or folic acid <br />screening. Your physician's determination of wx�cx exams/screenings you need will not be shared <br />with Roseville Human Resources; H.R. only needs to know you have had a physical exam and wHEtv <br />your physician wants to see you again. <br />This section is to be completed by employee's physician. <br />Clinic Name/Address Stamped Here: <br />Date of most recent wellness physical exam or screening: <br />Next physical exam or screening should occur by the end of <br />Physician's signature: <br />AND <br />Month and vear <br />B. A Blood Pressure Screening performed by a qualitied medical professional is required every year. <br />This screening can be a part of a visit to your physician, blood donation center, or the neighborhood <br />fire station. <br />Screener's Company Name, signature and date(s) to verify screening(s) <br />AND OVER • • <br />
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