ChooseWell

KC WELLNESS, INC.

Congratulations on your commitment to "ChooseWell" by completing an annual physical
with your personal health care provider in 2014.

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.

Results must be returned by July 31, 2014.

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.