Retain a copy of completed form for your records and return the original completed form to
District Compensation & Benefits office, Room 107, via intradistrict mail or in person.
Version 2 | 2021
2 0 2 1
WELLNESS REBATE
CERTIFICATION FORM
For Employees with
SUTTER HEALTH PLUS (SHP)
Medical Coverage
(Payment Authorization and
Wellness Consultation Information)
First Name: ________________________
Last Name: _________________________________
Phone #: __________________
Confirmation Email: _________________________
Work Location: ___________________________
2. Glucose & Cholesterol Screening
Completed: _______________________________________________
Employee’s Physician/Representative
Contact your primary care physician (PCP) to request an appointment and obtain an order for glucose and cholesterol screening lab work. Once the lab work has been
ordered, you may go to any Sutter laboratory for the screening, with or without an appointment. There is no copay for this screening. A copay may be required if your PCP
decides you require more comprehensive labs. Fasting is recommended but not required. To show that you have met this requirement, have your PCP sign the “Completed”
field (above) at the end of your Wellness Consultation. Do not ask laboratory personnel to sign this form.
3. Health Risk Assessment
Completion Date (per employee): ________________
A health risk assessment is a series of questions to help you become aware of possible health risks. EGUSD will not have access to your individual answers. To complete this
requirement, take the Personal Health Assessment (PHA) offered through Sutter Health Plus by visiting http://blogs.egusd.net/wellness/ and clicking on the health risk
assessment logo. After finishing the PHA, enter the date it was completed in the space above.
4. Wellness Consultation
Including Blood Pressure & Body Mass Index (BMI)
Completed: _______________________________________________
Employee’s Physician/Representative Signature
A Wellness Consultation is a clinical visit that includes information regarding recommended age-appropriate screenings
and a review of your biometric screens (glucose and cholesterol screening), blood pressure screening, BMI, and health
risk assessment. Blood pressure screening and BMI, which is a height and weight measurement, will be completed as
part of your Wellness Consultation. One Wellness Consultation appointment every 12 months is a zero co-pay visit. If
your Wellness Consultation becomes a more comprehensive appointment about matters outside the area of the
Wellness Consultation, the visit may be subject to a copay.
5. Employee Certification
Before submitting this form, did you:
Complete shaded items 1, 3, and 5?
Obtain approvals from your Primary Care Provider (PCP) for items 2 and 4?
I certify that I have completed the necessary requirements above and hereby authorize my Sutter Health Plus medical provider to confirm that I have received an annual
Wellness Consultation and have been informed of recommended age-appropriate screenings. I understand that completed forms are subject to verification. No private health
information is to be disclosed as part of the confirmation.
Employee Signature: ______________________________________________________
Instructions on Completing Wellness Rebate Certification Form for Sutter Health Plus (SHP) members:
Schedule an appointment for May 31, 2020 or after with your Primary Care Provider (PCP). Inform the staff that you are an EGUSD employee calling to schedule a wellness
consultation and request labs for glucose and cholesterol screening.
NOTE: SUTTER HEALTH PLUS ALLOWS ONE WELLNESS CONSULTATION EVERY 12 MONTHS AT NO CHARGE
Complete labs at a Sutter laboratory facility at least two days prior to the appointment.
Complete the online health risk assessment (see Box 3 for more information).
Complete the appointment with your PCP – bring this form and ask the PCP to approve Boxes 2 and 4 above.
Review the form to ensure items 1-5 are completed (employees are to complete shaded items), retain a copy of form for your records, and return the original form to EGUSD
Compensation & Benefits office via intradistrict mail or in person.
Form due no later than October 1, 2021. Forms will be accepted starting November 2, 2020
PROVIDER USE ONLY
For billing/encounter reporting, use the appropriate CPT
and ICD codes from the following list: This visit has $0
member cost share
99401 (Preventive counseling, 15 minutes)
99402 (Preventive counseling, 30 minutes)
Z00.00 (Encounter for adult health check-up NOS)
Z00.01 (Encounter for general adult medical examination
with abnormal findings)
