Practice Wellness Grant
Practice Wellness
Grant Application & Commitment to Implement


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Grant Application & Commitment to Implement

Practice Name *
Number of employees enrolled as of this application *
Name of person responsible for
grant criteria completion *
Title *Phone *Email *

Reimbursement Criteria:

  • Core Only: $25/per enrolled employee (based on enrollment at time of completion)
  • Core and ONE metric from Core+ More: $50/per enrolled employee (based on enrollment at time of completion)
  • Core and TWO metrics from Core +More: $100/per enrolled employee (based on enrollment at time of completion)
  • Unless otherwise noted, all chosen components must be completed within a 12 month period from the effective date of implementation
  • The minimum grant is $250 and the maximum grant is $20,000.

All four of the following items must be completed:

  1. Meeting with NCMS Plan Health Promotion Coordinator to review grant program.
  2. Signed Executive Commitment to demonstrate dedication to a culture of wellness.
  3. NCMS Plan's preventive benefits and wellness resources promoted to practice population.
  4. Creation and communication of at least ONE written wellness policies (e.g., tobacco free, healthy eating, work/life balance, wellness participation, physical activity).
Choose ONE of the following: *

Health Assessment completion by 75% of enrolled employees.


Commit to a coordinated 45 minute educational/skill building workshop with at least 50% practice participation.


Participation/Outcome-based incentive strategy integrated into practice benefit plan.


Coordinate TWO service events (e.g.. local charity race, community project, food bank) with at least 25% participation AND ONE of the following:


      A. Coordinate a financial seminar for employees (e.g., personal finances, budgeting, or retirement planning)

      B. Training/workshop that addresses weight management, stress management, resilience, or building individual capacity

Annual preventive care exam and/or age/gender appropriate screenings completed by 75% of enrolled employees.
For Practices with an existing comprehensive wellness program as determined by the NCMS Plan Health Promotion Manager, a practice may submit a grant proposal outlining alternative programming for the Grant Review Committee to consider. Please contact for further information.

I hearby

I hereby commit to implementing the above criteria in an effort to qualify for a Practice Wellness Grant and to incorporate key, defined elements of an effective and sustainable health promotion program. I understand that the NCMS Health Promotion Coordinator will assist me with achieving these steps by providing guidance and assistance.

Name *

Health Promotion Coordinator      ______________________________________

Grant Committee Member           ______________________________________

Date                                          ______________________________________