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0000 Molded Fiber Glass Tray Company 6175 US 6 Linesville, PA 164242021 Personal Wellness ProgramPhysical Verification Form Dear Physician, Our employee/teammate or their legal spouse is participating in a company sponsored personal wellness program designed to engage participants to make better health decisions and to receive regular routine preventive care. The requirement of our wellness program is that the Teammate receives an “Annual Physical” and provides to the company this Physical Verification Form*.For administrative purposes, your services and tests related to this annual physical will need to be coded as “ROUTINE PREVENTATIVE”.*Teammate / Spouse must be enrolled in a MFG medical plan to qualify for the Wellness Credit.Physician, please complete section below:Patient’s Name (Please Print Name Legibly) __________________________________________ The above participant was given a physical examination consistent with the standards of care applicable to his/her age, gender, and personal health history. Physician Signature ____________________________________________________ Printed Physician Name __________________________________________________ Date of Service: _____ /_____ /_______Teammate: To receive credit for your participation,please return this form to the Human Resources Dept.Name of MFG Tray Teammate if this is for a Spouse: _____________________________ ................
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