Everyone can do their share for better health. 

Employees on District Health Insurance:  Those enrolled on Nebo Health insurance usually DO NOT need to complete this form and return it.  However, if you are completing your preventative exam February 1 to June 1, complete this form and return it ASAP to the District Office.  Then you will get credit for the preventative exam requirement to help avoid the $200 penalty. Select Health will still verify your completion of a preventative exam through the use of CPT billing codes.  There can be a several week delay in the verification, hence the need to use this form to quickly document your visit with the District Office.  

Employee eligible for Nebo District insurance but not enrolled:  Completes the Preventative Exam requirement for My Share Wellness Prize ($50 gift card, Fit watch, or Wellness Day).  This will include "dependent dual employees".  

Employees not eligible for Nebo health insurance:  Complete this form and return to the Wellness Office at the District Office to receive a $35 gift card. To qualify:  Must work at least 2 hours a day.  Retirees, employees under 18, seasonal and substitutes not eligible.

Spouses on District Health Insurance:  Complete this form and return to the Wellness Office at the District Office to receive a $35 gift card.  All other spouses are NOT eligible for the $35 gift card. 

 

Preventative Exam form 

 There are five requirements to complete or be current (up to date) on the following:

  1. Complete a physical examination from a physician based on age, gender and risk factors.
  2. Complete physician recommended preventative cancer screenings based on age, gender, and genetic risk factors. i.e. mammogram, pap smear, colonoscopy, etc.
  3. Complete a blood chemistry panel within the last 2 years.  More frequent if physician recommends based on risk factors.   Screened items are:  Glucose levels, LDL cholesterol, total cholesterol, and triglycerides.  Patient should receive this information.  
  4. Discuss immunization status.
  5. Discuss recommendations to address present risk factors.  These recommendations should include any prudent professional interventions (i.e. prescriptions) and lifestyle changes (activity and dietary changes).    

Return the signed Employer’s copy of the Preventative Exam form the "Wellness Office" or John Allan at the District Office via IMC, mail or hand delivery.  Copies, images and facsimiles are accepted.   Email: john.allan@nebo.edu  Fax: 801-342-8023. 

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