ChooseWell

KC WELLNESS, INC.

Congratulations on your commitment to “ChooseWell” by completing an annual physical
with your personal health care provider between January 1 and April 30, 2012.

Please complete and submit the requested information below. You will receive a packet by
mail in approximately 2 weeks to complete and return to KC WELLNESS, INC.

Only Full Time and Regular Part Time LGE-KU employees are eligible to participate.

Employee ID:
Date:
First Name:
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip:
Phone:

Take me Back

*KC WELLNESS, INC. will handle your information in compliance with all applicable HIPAA regulations.
Your employer will only be notified when we receive your completed packet.
Please contact us at 877-634-1412 with questions.