Medicare Wellness Rewards Attestation

If you completed an annual wellness visit within the current calendar year, please provide the following information. We will add your reward onto your FlexCard for you. If you have questions, please call our Health Plan Services at 303-602-2111. You may only qualify for this reward one time per calendar year.

By submitting this form, you are confirming you completed an annual wellness visit during the calendar year.

First Name *

Last Name *

Elevate Medicare Member ID*

Date of Birth*

Date of Visit*

Rate Your Visit*

Promotion Details

Medicare Annual Wellness Visit Reward

Terms & Conditions
Reward offered for annual wellness visits completed between January 1 of current year and December 31 of current year. Reward request must be submitted on or before 01/31/2025. Reward issued one time per screening, per calendar year. Reward will be applied to your Elevate Medicare FlexCard within 3-5 days of submitting the form.

*Field is required