• Appalachian Regional Healthcare Wellness Plan Request

    Please fill out the form below and submit required documents prior to December 31, 2022
  • *Before beginning, read all requirements and ensure you have the completed documentation for you and your spouse if applicable. You will not be able to save your information and return at a later date.*

  • If you selected the Wellness Plan during Open Enrollment for the 2023 plan year, complete this form to document that you (and your spouse, if covered) have met all requirements. If the Wellness Plan was selected and all criteria are not documented in this portal, the health plan selection will be corrected to the Standard Plan for 2023.

  • 1) Employee (and spouse, if covered) must:

    a. Be Tobacco Free

    i. Use of any tobacco product by employee OR covered spouse disqualifies the employee from the Wellness Plan

    ii. Per FDA definition, tobacco products include: cigarettes, cigars, dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll your own tobacco, smokeless tobacco, vaporizers, e-cigarettes, and other electronic nicotine delivery systems

    b. Receive the 2022-2023 flu shot OR have an ARH approved medical or religious exemption (previous approved religious exemptions are still in effect; medical exemptions must be requested again)

    c. Complete a wellness lab panel and a physical exam and upload the signed physical form.

    i. Print a physical form: https://www.arh.org/wp-content/uploads/2022/09/2023-Wellness-Plan-Documentation-Form-1.pdf

  • For More Information:

    Refer to the ARH Benefit Guide: https://www.arh.org/wp-content/uploads/2022/09/FINAL-2022-ARH-BENEFIT-GUIDE-105.pdf

  • After your request has been reviewed and processed, you will be notified in writing via email of approval or denial. Failure to submit required documentation will result in denial of your request, and you will be enrolled in the standard health plan for the upcoming year.

  • Incomplete submissions will not be reviewed. Be sure all forms and documentation are submitted at one time.

  • Answer each of the statements below:

  • To download, print and fill out the 2023 Wellness Plan Documentation Form visit:

    2023 Wellness Plan Documentation Form: https://www.arh.org/wp-content/uploads/2022/09/2023-Wellness-Plan-Documentation-Form-1.pdf

  • If your spouse is covered on your plan, answer each of the statements/questions below with your SPOUSE’S information:

  • To download, print and fill out the 2023 Wellness Plan Documentation Form visit:

    2023 Wellness Plan Documentation Form: https://www.arh.org/wp-content/uploads/2022/09/2023-Wellness-Plan-Documentation-Form-1.pdf

  • Incomplete submissions will not be reviewed. Be sure all forms and documentation are submitted at one time.

  • Clear
  • Should be Empty: