Request for Accommodations for the Wellness Incentive Program Due to Sincerely Held Religious Beliefs

This form should be used when requesting  accommodations for the Wellness Incentive Plan due to sincerely held religious beliefs.

Step 1: Review and acknowledge the information below. 

Step 2: Submit the completed request form.

To request disability accommodations as the basis for exemption from the COVID-19 vaccine, please contact the Deputy Compliance Officer at or by calling 417-836-6755.

Missouri Department of Health and Senior Services Novel Coronavirus Fact Sheet.
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