ANNUAL PREVENTATIVE CARE EXAM FORM
Member Name: _______________________________________
Employee #: ____________________
Employer: City of Little Rock
The above referenced member is my patient and completed an Annual Preventative Care Exam
on (mm/dd/yyyy) ____________________.
Physician’s Name and Office Location:
______________________________
______________________________
______________________________
______________________________
Physician’s Signature: _________________________________ Date: ____________________
As a participant in the City of Little Rock’s Wellness Program I am required to have an Annual
Preventative Care Exam. The Annual Preventative Care Exam has to be completed between
January 1, 2021 and December 31, 2021.
Employee’s Signature: ________________________________ Date: ____________________
Please return this form to:
City of Little Rock
Benefits Division
500 W. Markham Suite 130W
Little Rock, Arkansas 72201
Fax: (501) 371-4496
