2012 Valencia Incentive Points Program Take this form to your health care provider(s) to report the completion of the preventive care services completed in 2012. After filling in the information below, fax this form to 407.582.8202 or send to Debi Jakubcin mail code 3-33 by December 31, 2012. Note: All fields are required. If you do not include all information, you will not receive credit for your activity.
VID #
Employee Completion CIGNA Health Plan ID:
Last Name:
First Name:
Work Phone:
Date of Birth MM/DD/YY:
Gender:
M F
Preventive Care Milestone Requirements (check one):
Annual Physical (required) Mammogram Colonoscopy Dental Preventive Cleaning Flu shot Doctor or Health Care Professional Verification (to be completed by provider) Doctor/Health Care Professional’s Note: Your signature is confirmation that the preventive care services noted above have been completed Print Name: Provider ID: Signature: (Last, First)