Ready for My Recovery 1-Year Attestation Form

This form is confidential.

This form is to be completed ONLY by individuals that have been enrolled in the Ready for My Recovery program and have completed 12+ months of continuous recovery.

Congratulations on completing 12 months of recovery engagement! This attestation form is to be completed for every six additional months thereafter that you have engaged in continuous recovery services and/or recovery activities listed below. Completing the form allows you to keep earning My Health Pays® rewards** as you continue your recovery.

*Required Field

Today's Date (MMDDYYYY):

Your First Name: *

Your Last Name: *

Your Birth Date (MMDDYYYY): *

Mailing Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone

Email:

Best Day/Time to Reach You:

I hereby attest to my six months of engagement in one of the following recovery efforts: Peer Recovery support services Recovery Support services 12-Step Program Smart Recovery Refuge Recovery Program Recovery-friendly workplace employment Enrolled and engaged with Job Launch or similar program Recreational Recovery Activity Engagement Other Recovery Support Engagement Activity

If Recreational Recovery Activity Engagement or Other Recovery Support Engagement Activity please explain:

The above recovery took place from (MMDDYYYY):

To (MMDDYYYY):

Signature (Please Initial):

If you need immediate assistance with substance use, please call 2-1-1.

Note: Tobacco/nicotine use are not included as part of this program.

**Some restrictions and limitations apply. Each member can earn up to $250 in cash and non-cash goods and services through June 30 each year.