Physician Medical Waiver – Healthy Living Checklist

1 Physician Medical Waiver Healthy Living Checklist As a company that cares about the health and wellbeing of our associates, The Home Depot encourages all of its associates to take an active role in learning about and managing their health risks. Associates and their spouses who enroll in a Home Depot Medical Plan (in the continental US) can receive a Medical payroll deduction discount ( Healthy Living Program Discount ) if they (1) complete the OrangeLife Questionnaire, (2) participate in a biometric health risk screening, and (3) complete two of three available items (one by May 1 and a second by September 1) on a personalized Healthy Living Checklist . The Healthy Living Checklist can be accessed by logging on at Participating in the Healthy Living Program steps is voluntary. Choosing not to participate will only result in not receiving the Healthy Living Program Discount.

2 If your Physician believes that completing one or two of the Checklist items is medically inappropriate in your individual situation, he/she can complete this Physician Medical Waiver and the patient will receive a Waiver for one or two of the Checklist items, as applicable. Physician : Review this Waiver carefully, attest to the appropriate information and then sign and date the form at the bottom. Patient (associate or covered spouse): Sign and date the form and return the completed Waiver by fax to 847-883-8269 no later than later than the deadlines listed below. Healthy Living Program Discount Revoke Notice May 1 Checklist Deadline - Waivers received after May 1, 2019 may result in revoke of the Healthy Living Program Discount and can only be reinstated 1) once Waiver is received and processed or 2) completion of a Checklist activity. September 1 Checklist Deadline Waivers received after September 1, 2019 will result in revoke of the Healthy Living Program Discount and will not be reinstated.

3 The information that you provide on this form will be kept confidential and will not be used for any purpose other than to determine if the patient is eligible for a Waiver of one or two of the Checklist items. For more information, view the Wellness Program Notice available at PART I Prescribing Physician 's Information (please print). Please mark the item(s) on the Personalized Healthy Living Checklist in which you are providing a Waiver : Annual Physical Shingles Vaccination Video Where to Go for Care Video Skin Cancer Breast Exam Accordant Action Plan Video Asthma Video Stress Colon Screening Lung Screening Video Barometric Pressure Video CPR. Cervical Cancer Screening Hello Heart (BP Monitor) Video Gratitude Video Sun Exposure Diabetic Eye Exam Sleepio Sleep Test Video Mindfulness Health Quest Dental Cleaning Register Grand Rounds Video Happiness As the patient's treating Physician , I hereby attest that it is medically inappropriate for the patient to complete the Checklist item(s) checked above.

4 Physician Signature: Physician UPIN/NPI: Physician Name: First_____ Last_____ Date:_____. Address:_____ ZIP_____ Phone Number:_____. PART II Patient's Information (please print). I acknowledge that falsification of Company records may result in discipline for me or my spouse under Home Depot's Standards of Performance. Patient Name: First_____ Last_____. Date of Birth: Month_____ Day_____ Year_____ Healthy Living ID1:_____. Phone Number:_____ Email Address2:_____. Patient Signature:_____ Date:_____. 1 If you need this number, please call the Benefits Choice Center at 800-555-4954. 2 The Benefits Choice Center will email you a confirmation of receipt of this form within 48 hours. If you do not receive a confirmation of receipt email from the Benefits Choice Center within 48 business hours, or have questions about the Waiver process, you can call 800- 555-4954.

5 Associate or Spouse: Please ensure all fields above are completed and retain a copy of this form for your records