Harvard Pilgrim Fitness Reimbursement Form Page 2
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4Harvard Pilgrim Fitness Reimbursement Form
To be filled out by Harvard Pilgrim Health Care SUBSCRIBER only. Please use blue or black ink and print all information clearly.
When to submit this form
• After your employer has added the fitness reimbursement program.
• After you have been a member of a fitness facility and Harvard Pilgrim Health Care for at least four months in a calendar year.
• Once per calendar year, submitted by March 31 of the following year, with all necessary receipts or proof of payment.
• Once all sections have been completely filled out and signed by the subscriber.
Section A – Subscriber Information (person who holds coverage)
Harvard Pilgrim ID Number
Subscriber’s Last Name
First Name
Middle Initial
Date of Birth (mm/dd/yyyy)
Address
City
State
ZIP Code
Daytime Phone (area code) xxx-xxxx
Company Name (Employer)
Subscriber’s Email
Section B – Subscriber and/or Member Information for Reimbursement
Harvard Pilgrim ID Number
Last Name
First Name
Date of Birth (mm/dd/yyyy)
Harvard Pilgrim ID Number
Last Name
First Name
Date of Birth (mm/dd/yyyy)
Harvard Pilgrim ID Number
Last Name
First Name
Date of Birth (mm/dd/yyyy)
Section C – Fitness Facility Information
(List all health clubs and facilities that you and/or your dependent(s) are submitting
for reimbursement listing the qualifying four months.)
Calendar Year
from: mm/dd/yyyy
Phone Number
$ Amount
Facility Name
City, State
being claimed
to: mm/dd/yyyy
(Area Code) xxx-xxxx
from: ____/____/____
to: ____/____/______
from: ____/____/____
to: ____/____/______
from: ____/____/____
to: ____/____/______
Total number of documents _____Total dollar amount being claimed $_______________
Section D – Subscriber Certification
I certify the information on the form and all supporting documents are complete, accurate and unaltered. I will
attempt, in good faith, to regularly attend my fitness facility and use the membership for which I am being reimbursed.
Subscriber’s Signature
Date
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