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When submitting your screening form:

Screening forms for the previous year MUST be submitted by March 1st in order to be processed.
Ensure your name matches your health account.
Processing may take up to four (4) weeks.
Only one (1) of each screening type per year, per employee.
Incomplete requests or missing documentation will not be processed.

Employee/Retiree ID Number: *

Last Name: *

First Name: *

Middle Name:

Email: *

Date of Birth: *

Main contact phone number: * Required format: 111-222-3333

Date procedure was performed: *

ATTACH DOCUMENTATION FROM PHYSICIAN'S OFFICE

Documentation must include:

PLEASE NOTE:

Please upload documentation: *

Allowed: .tif, .pdf, .jpg, .png, .doc (max 250 MB)

Thank you!

Your form has been submitted successfully. A member of the BEWell team will review your submission and follow up if needed.