Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Wellness MAPS New/Renewal Application Form for 2019 Qualifications

  1. MAPS

  2. New or Existing MAPS member*

  3. Current Employee or Retired*

  4. Union/ Non-Union*

  5. Healthcare Provider*

  6. Suggestion: You may still want to upload your verification document. This will eliminate any required steps if you fall within the audit. Please do not submit and private health information.

  7. Wellness Activity*

    Which Wellness activity(s) have you completed?

  8. Provide the date for one of your Wellness Activities

  9. Will you be entering applicable spouse information?*

  10. Suggestion: You may still want to upload your verification document. This will eliminate any required steps if you fall within the audit. Please do not submit and private health information.

  11. Wellness Activity*

    Which Wellness activity(s) have you completed?

  12. Provide the date for one of your Wellness Activties

  13. Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking the submit button, I certify the above statements to be true and correct to the best of my knowledge, information and belief.

  14. I authorize the information to be used for the purpose of processing my MAPS qualification on a one time basis.

  15. I understand that my Wellness Medical and Activity Verification form can only be submitted one time and that multiple submissions will not be accepted.

  16. I understand that any false statements, omissions, or inaccuracies on the Wellness Medical and Activity Verification Form shall disqualify me and my dependents from MAPS qualification for this year and subject me and my dependents to mandatory audit for the following qualifying year.

  17. I further understand that the responses submitted are subject to random audit by Human Resources and that I will cooperate and provide verification of my responses as requested by Human Resources. Failure to comply with the audit requirements shall disqualify me and my dependents from MAPS qualification.

  18. I further understand that any audit, revealing false statements, omissions or inaccuracies, shall be placed within my personnel file.

  19. Leave This Blank:

  20. This field is not part of the form submission.