PIH Health 2023 Wellness Incentive Program Preventive Care Exam Attestation Form

Important: For details about the PIH Health 2023 Wellness Incentive Program, visit the MyBenefits.Life site.

Note: The PIH Health 2023 Wellness Incentive Program is offered by PIH Health. Blue Shield took no role in designing the PIH Health 2023 Wellness Incentive Program and has no financial responsibility for the program.

Your email address may be used to contact you about this form, if necessary.

*All fields below must be completed.

As a PIH Health employee and a Blue Shield of California medical/Rx plan subscriber, I hearby declare that I have completed my 2022 preventive care exam. *

Today's Date

Subscriber Last Name *

Subscriber First Name *

Subscriber Date of Birth *

Subscriber Blue Shield of California ID Number *

Subscriber Email Address *

Date of Preventive Care Exam *

Provider Name *

Provider Phone Number *

Questions about this form?

Contact your dedicated Shield Concierge team at (855) 599-2657, from 7 a.m. to 7 p.m., Pacific time, Monday through Friday.