INSTRUCTIONS: ALABAMA STATE EMPLOYEES' HEALTH INSURANCE PLAN WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

Alabama state employees use form IB07 to obtain a wellness discount certification after participating in a worksite wellness screening and completing one of the requirements to reduce health risks. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 1: Print your name in the first blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 2: Indicate whether you are male or female with a check mark.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 3: Enter your age in the second blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 4: Enter your contract number in the third blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 5: Enter your Social Security number in the fourth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 6: Enter your date of birth in the fifth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 7: Enter your daytime phone number, including the area code, in the sixth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 8: Check the first statement if you were counseled by your health care provider about the health risks identified in your wellness screening results and are attaching either a Wellness Program Office Visit Referral or a Completed Provider Screening Form. Indicate which with a check mark.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 9: Check the second statement if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates you attended.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 10: Check the third statement if you participated in a SEIB fitness center's wellness program. Enter the name and phone number of the program, the dates you attended and a program description.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 11: Check the fourth statement if you are self-managing your health risks and attach valid proof.