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I was counseled by my healthcare provider regarding the health risk s identified in my wellness screening results and I have attached one of the following A Wellness Program Office Visit Referral that has been signed by my healthcare provider or A completed Provider Screening Form documenting my results. The identified health risk must be addressed on or before October 31st for a January 1 premium discount. I participated in a Physician Supervised Weight Management/Nutritional program. Name...
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Revised 1016 is a form used for reporting revised information related to tax filings or other financial documentation.
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