2022 WSP USA Wellness Program

Annual Physical Exam Verification Form

Instructions: Please bring this form to your annual wellness exam. After completing the exam, have your
doctor fill out the Physician Certification section below. Next, upload the form by November 30, 2022 to
https://wsponline.sharepoint.com/sites/US-PreventiveWellness.

Employee Information (this section to be completed by employee)

I understand participation in the 2022 Live Well Preventive Care campaign is voluntary, and that this is for a preventive annual
wellness exam. If other diagnostic tests/services are performed, I will be responsible for out-of-pocket costs based on my
insurance plan.
Employee’s full name (printed): ________________________________________________________________________
Employee signature: _________________________________________________________________________________
Employee ID number: ________________________________

Dear Health Care Provider:

Your patient is involved in an employer-sponsored wellness program. WSP USA has asked employees to have
a preventive annual wellness exam. WSP is not requesting records or PHI pertaining to this exam. Completion
and submission of this form is necessary for your patient to be eligible to earn an incentive. Thank you for your
assistance.

Physician Certification (this section to be completed by the physician office)

By completing and signing below, we certify that we have provided an annual physical examination of this employee as one of
the following (primary care physician, family practitioner, general practitioner, internal medicine, or one of their physician's
assistants or nurse practitioners: no specialists allowed such as gynecologists, cardiologists, surgeons, urgent care facility
doctors, etc.).

PLEASE COMPLETE ALL INFORMATION BELOW

Date of annual physical examination:_________________ NOTE: Must be completed between 09/1/2021 - 11/30/2022

Physician name: ___________________________________________________________________________

Physician phone number: ___________________________________________________________________

Physician signature: ________________________________________________________________________

Date: ________________________________

Submission Instructions for Employee PLEASE NOTE

Submit this completed form in pdf or jpg format by uploading it to: To be eligible for the incentive
https://wsponline.sharepoint.com/sites/US-PreventiveWellness. raffle program, this form must
be submitted by November 30,
2022.
You may also submit the form via email to wellness@wsp.com.