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Wellness Incentive Completion Form
Fill out the information below and click on the SUBMIT button at the bottom of this form.
If you have proof of completion, (certificate of participation, receipt), please submit a copy of the certificate.

You can upload a copy, email a copy, mail a copy or visit one of our offices in Santa Fe or Albuquerque and drop off a copy.

* UPLOAD A COPY OF YOUR CERTIFICATES:
Click on the link below or copy and past the link into your web browser
https://script.google.com/macros/s/AKfycbz9v3rqp-gz8A1NEp3xBTiULk1LJwZdFR6VkSqK45HNcPP7ioo/exec

* EMAIL A COPY OF YOUR CERTIFICATES:
NMRHCA.wellness@state.nm.us

* MAIL:
Retiree Health Care Authority
4308 Carlisle Blvd. NE, Suite 104
Albuquerque NM, 87107-4849

Name *
Your answer
Email
Your answer
Address *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone number
Your answer
Last 4 digits SSN
Your answer
First Wellness Program *
Your answer
Second Wellness Program *
Your answer
Check Applicable Health Plan
Certificate Submission *
If you have any questions, please contact us at 1-800-233-2576 or email us at NMRHCA.wellness@state.nm.us
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