Scan your completed and signed form and save it to your computer. Log in to your Virgin Pulse account and select the 'Benefits' tab, then locate the 2023 Biometric Screening Verified Form. Click on 'Start Now' and upload the form from your computer. Alternatively, you can fax the form to 401-735-5853 but be sure to keep a copy of the fax receipt. Ensure all required metrics and signatures are complete before submission. Submission deadline is July 31, 2023. For any questions or assistance, contact Virgin Pulse customer support at support@virginpulse.com or call 855-954-1861.

The important dates for this form are Aug. 1, 2022, to July 31, 2023, for the current program year. The submission deadline is July 31, 2023. Make sure to complete and submit the form within this period to be eligible for the 2023 Annual Wellness Assessment program.

The purpose of this form is to record and submit biometric screening results for participants of the 2023 Annual Wellness Assessment program. Completing this form ensures you and your covered spouse, if applicable, provide the necessary health metrics to Virgin Pulse. Timely submission is essential to receive wellness credits and qualify for potential premium discounts in the following year. By submitting the form, you help your organization collect vital health data that can improve future wellness programs. This data allows for more personalized health plans and effective wellness initiatives within the organization. Participating in the wellness assessment program emphasizes the importance of preventive care and maintaining a healthy lifestyle. Ensuring that all required fields are completed accurately and submitted before the deadline is crucial. Missing or incorrect information can result in delays or disqualification from receiving wellness credits for the program year. Adhering to the instructions and guidelines provided helps streamline the process for both participants and administrators.

• 1. Member Information: Includes personal details such as name, unique member code, and contact information.
• 2. Biometric Metrics: Contains fields for recording health metrics like blood pressure, cholesterol levels, and glucose levels.
• 3. Primary Care Provider Information: Includes PCP's name, contact information, and signature fields.
• 4. Member Signature: Fields for the signature of the member confirming the accuracy of the submitted information.
• 5. Submission Instructions: Provides guidance on how to submit the completed form through various methods.

Failing to submit the form can result in disqualification from receiving wellness credits and potential premium discounts for the following year. It is important to adhere to the deadlines and submission guidelines to avoid negative consequences.

• Loss of Wellness Credits: You will not receive the wellness credits that contribute to your rewards and assessments.
• Disqualification from Program: Ineligibility for the 2024 premium discount and other program benefits.
• Delays in Approval: Submission after the deadline may result in processing delays and additional follow-up requirements.

• 1. Completed Biometric Screening: Use this form if you have completed your biometric screening with your PCP between Aug. 1, 2022, and July 31, 2023.
• 2. Submitting for Wellness Program: This form is necessary to participate in the 2023 Annual Wellness Assessment program and receive related credits.
• 3. Spouse Participation: Covered spouses need to use their individual forms to submit biometric screening results.