2. 
3. Employee Last Name*
4. First Name*
6. New or Existing MAPS member*

   1. New member for 2023
   2. New Hire
   3. 2022 Member
7. Current Employee or Retired*

   1. Current Employee
   2. Retired Employee
9. Department*
10. Union/ Non-Union*

    1. UMWA
    2. WCCREA
    3. SEUI
    4. Park Police
    5. Children's Bureau
    6. Detectives
    7. District Attorney
    8. WCAPE
    9. Non-Union
    10. Prison Professionals
12. Phone*
13. Email*
15. Healthcare Provider*

    1. UPMC

    1. Highmark
16. Member ID (on front of card)
18. Date of Wellness Exam*
    Date of Wellness Exam
19. Physician/ Practice Name*
21. Physician/ Practice Address*
22. Physician/ Practice Phone*
24. Upload Supporting Documentation for Wellness Exam
    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.
26. Preventative Activity*

    Which Preventative activity(s) have you completed?

    1. Mammogram
    2. Colonoscopy
    3. Gynecology Exam
    4. Eye Exam
    5. Dental Exam
    6. Bone Density Test
    7. Health Risk Assessment
    8. RealAge Test (sharecare.com)
    9. Shingle or Pneumonia or Flu Shot
    10. COVID Vaccine
27. Date of Preventative Activity*
    Date of Preventative Activity
    Provide the date for one of your Preventative Activities
29. Wellness Activity

    Which Wellness activity(s) have you completed?

    1. Enrollment into a weight loss program/ diabetic counceling
    2. Attended a Wellness Lunch and Learn
    3. Attending a Wellness Fair
    4. Enrollment in a Smoking Cessation Program
    5. Active Participation in a Fitness center or certify 30 mins of weekly activity (3x/week)
    6. Certify active participation in a sports league or coaching (6 week minimum)
    7. Participate in a charity walk, run, swim, or bike
    8. Active Participation in a Wellness Challenge (Pedometer, Weight Loss, Hydration, etc.)
    9. Call to insurance Health Coach
30. Date of Wellness Activity
    Date of Wellness Activity
    Provide the date for one of your Wellness Activities
32. Will you be entering applicable spouse information?*

    1. Yes

    1. No
34. Spouse Name*
36. Date of Wellness Exam*
    Date of Wellness Exam
37. Physician/ Practice Name*
39. Physician/ Practice Address*
40. Physician/ Practice Phone*
42. Upload Supporting Documentation for Physical Exam

    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 any private health information.

44. Preventative Activity (spouse)*

    Which Preventative activity(s) have you completed?

    1. Mammogram
    2. Eye Exam
    3. Colonoscopy
    4. Gynecology Exam
    5. Dental Exam
    6. Bone Density Screening
    7. Health Risk Assessment
    8. RealAge Test (sharecare.com)
    9. Shingle or Pneumonia or Flu Shot
    10. COVID Vaccine
45. Date of Preventative Activity*
    Date of Preventative Activity
    Provide the date for one of your Preventative Activities
47. Wellness Activities

    Which Wellness activity(s) have you completed?

    1. Enrollment into a weight loss program/ diabetic counseling
    2. Attended a Wellness Lunch and Learn
    3. Attended a Wellness Fair
    4. Enrollment in a Smoking Cessation Program
    5. Active participation in a Fitness center or certify 30 mins of weekly activity (3x/week)
    6. Certify active participation in a sports league or coaching ( 6 week minimum)
    7. Participate in a charity walk, run, swim, or bike
    8. Pedometer Challenge (active participation)
    9. Call to insurance Health Coach
48. Date of Wellness Activity
    Date of Wellness Activity
    Provide the date for one of your Wellness Activities
50. 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.
52. I authorize the information to be used for the purpose of processing my MAPS qualification on a one time basis.
54. I understand that my Wellness Medical and Activity Verification form can only be submitted one time and that multiple submissions will not be accepted.
56. 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.
58. 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.
60. I further understand that any audit, revealing false statements, omissions or inaccuracies, shall be placed within my personnel file.
62. Employee Signature*
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field