Appalachian Regional Healthcare Wellness Plan Request

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.
Date of Request*

MonthDayYear
Status at ARH*

EmployeeEmployee with covered Spouse
ARH Employee Number*
Primary Work Location*

ARH OUR LADY OF THE WAY HOSPITAL & CLINICSARH SYSTEM CENTERBARBOURVILLE ARH HOSPITAL & CLINICSBECKLEY ARH HOSPITAL & CLINICSHARLAN ARH HOSPITAL & CLINICSHAZARD ARH HOSPITAL & CLINICSHIGHLANDS ARH HOSPITAL & CLINICSMARY BRECKINRIDGE ARH HOSPITAL & CLINICSMCDOWELL ARH HOSPITAL & CLINICSMIDDLESBORO ARH HOSPITAL & CLINICSMORGAN COUNTY ARH HOSPITAL & CLINICSPAINTSVLLE ARH HOSPITAL & CLINICSSUMMERS COUNTY ARH HOSPITAL & CLINICSTUG VALLEY ARH HOSPITAL & CLINICSWHITESBURG ARH HOSPITAL & CLINICS
Status at ARH*
Primary Work Location*
Your Full Name*
Phone Number*
Please enter a valid phone number.
Email*
Please enter a valid email address.
Incomplete submissions will not be reviewed. Be sure all forms and documentation are submitted at one time.
Answer each of the statements below:
I have read and understand the eligibility requirements of the Wellness Plan and certify that any information provided here is true and accurate.*

YES
I confirm I requested the Wellness Plan rate during Open Enrollment.*

YESNO
I confirm I DO NOT use tobacco in any form (including cigarettes, cigars, dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll your own tobacco, smokeless tobacco, vaporizers, e-cigarettes, and other electronic nicotine delivery systems).*

I DO NOT use any tobacco productsI DO use tobacco products
I confirm I have received the 2022-2023 Flu Shot.*

Yes, I received the flu shot through ARH Employee HealthYes, I received the flu shot at a provider’s office, a flu shot event, or a pharmacy and proof has been submitted to the ARH Flu Vaccine PortalNo; I have an ARH approved medical or religious exemption
I confirm I have completed the required lab panel.*

YESNO
I confirm I have completed a physical examination with a licensed independent practitioner (doctor, nurse practitioner, or physician’s assistant).*

YESNO
Upload completed and signed “ARH Wellness Plan Documentation Form”*

Cancelof
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
Full Name of spouse:*
Does Spouse work for ARH?*

YESNO
Spouse's primary Work Location:*

ARH OUR LADY OF THE WAY HOSPITAL & CLINICSARH SYSTEM CENTERBARBOURVILLE ARH HOSPITAL & CLINICSBECKLEY ARH HOSPITAL & CLINICSHARLAN ARH HOSPITAL & CLINICSHAZARD ARH HOSPITAL & CLINICSHIGHLANDS ARH HOSPITAL & CLINICSMARY BRECKINRIDGE ARH HOSPITAL & CLINICSMCDOWELL ARH HOSPITAL & CLINICSMIDDLESBORO ARH HOSPITAL & CLINICSMORGAN COUNTY ARH HOSPITAL & CLINICSPAINTSVLLE ARH HOSPITAL & CLINICSSUMMERS COUNTY ARH HOSPITAL & CLINICSTUG VALLEY ARH HOSPITAL & CLINICSWHITESBURG ARH HOSPITAL & CLINICS
Spouse's primary Work Location:*
Spouse's ARH Employee Number:*
If your spouse is covered on your plan, answer each of the statements/questions below with your SPOUSE’S information:
I confirm my spouse does NOT use tobacco in any form(including cigarettes, cigars, dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll your own tobacco, smokeless tobacco, vaporizers, e-cigarettes, and other electronic nicotine delivery systems).*

My spouse DOES NOT use tobacco productsMy spouse DOES use tobacco products
I confirm my spouse has received the 2022-2023 Flu Shot.*

Yes, my spouse is an ARH employee and received the flu shot through ARH Employee HealthYes, my spouse received the flu shot at a provider’s office, a flu shot event, or a pharmacy and proof has been submitted to the ARH Flu Vaccine PortalNo, my spouse has an ARH approved medical or religious exemption
I confirm my spouse has completed the required lab panel.*

YESNO
I confirm that my spouse has completed a physical examination with a licensed independent practitioner (doctor, nurse practitioner, or physician’s assistant).*

YESNO
Upload your spouse's completed and signed “ARH Wellness Plan Documentation Form”*

Cancelof
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.
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Appalachian Regional Healthcare Wellness Plan Request

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

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ARH BIG SANDY REGION

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