Physician Verification Form

Use the Physician Verification Form (PDF) to request a medical waiver or update us on the progress of patients enrolled in a wellness plan. This includes Healthy Blue Achieve℠ and other plans that track health measure targets.

There are two sections on the form. Only one might apply to your patient.

  • Medical Waiver: Fill out this section when you believe your patient can’t meet the health measure targets or activity requirements of their plan due to a medical condition.
  • Health Measure Achieved: Fill out this section if you have a patient who didn’t meet a health measure target in the past, but has recently met the target. Doing this doesn’t guarantee that the patient will get the lower out-of-pocket costs associated with the plan.

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