Add additional location (Complete Section 1) Address/phone/e-mail change (Complete Section 1) Discount change (Complete Sections 1 & 2) I do not wish to participate in Healthy Living Rewards I do not wish to participate in Healthy Living Rewards for Kids
Section 1 If updating your address and/or contact information, please complete this section.
*Required Information
Name of Organization or Business:*
Contact Name:*
Business Address 1:*
Business Address 2:
City:*
State:*	Select One Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip Code:*
Phone:*
Phone Type:	Select One Home Cell Work
E-mail:*
Confirm E-mail:
Website (if applicable):
Section 2 If updating or changing your currently offered member discount, please complete this section.
Member discount for Healthy Living Rewards Program and description (if applicable):
Member discount for Healthy Living Rewards for Kids Program and description (if applicable):
The discount information from Section 2 will be updated in our records and published to our members via our website and various printed materials. Please sign and date below to confirm your agreement with the above information.
Authorization Name:* By entering your name, you authorize the above incentive to be used by UPMC Health Plan members.
Date:*	(MM/DD/YYYY)

Healthy Living Rewards provider directories listed on our website are updated monthly.

Thank you for participating in the Healthy Living Rewards Program. The discounts you are offering will help to promote and improve the general well-being of our members.

Healthy Living Rewards Program: 412-454-8810.
Healthy Living Rewards Program Fax: 412-454-6110.

UPMC Health Plan is not affiliated in any manner with, nor does it endorse, participating establishments in the Healthy Living Rewards Program or the Healthy Living Rewards for Kids Program.

UPMC Health Plan accepts contacts via e-mail for requests for information or other inquiries only. To enroll, disenroll, or submit an appeal, complaint, or grievance, please contact Member Services by phone or through regular mail. UPMC Health Plan will not accept enrollments, disenrollments, appeals, complaints, or grievances through this website. We apologize for any inconvenience this may cause.