Member Reimbursement Fitness Club Form
Download a blank fillable Member Reimbursement Fitness Club Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Member Reimbursement Fitness Club Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Member Reimbursement Fitness Club Form
(Please print clearly, complete all sections in blue and sign. Retain a copy of all receipts and documents for your records)
1. Member’s Tufts Health Plan #
2. Member’s Name (Last, First, Middle Initial)
3. Member’s Date of Birth
/
/
4. Member’s Relationship to Subscriber
sex:
M
F
Self
Spouse
Child
Other
5. Subscriber’s Name:
6. Fitness Club Name:
Address:
Address:
Telephone:
(
)
-
Telephone:
(
)
-
7. In what setting did the member receive treatment?
8. Outside the USA:
(e.g.: office, ER, hospital, clinic, ambulance, etc.)
In what country was the member seen? _____________
In what language was the bill written? ______________
Fitness Club
In what currency was the bill paid? ________________
9. DIAGNOSIS: What were you seen for?
Diagnosis Code: 799
Description: General
A
B
C
10.
Year of fitness club
Procedure code and/or description of procedures, services, or supplies provided
Amount paid
membership
* T4220 Health club membership, annual
*
*
11. Total Amount Paid:
12.
roof of service(s) through one of the following:
P
An itemized bill from the fitness club, listing year of membership, and dollar amounts paid
13.
roof of payment through one of the following:
P
The front and back of the cancelled check written to the fitness club or the bank encoded front of the check written
to the fitness club;
A credit card statement or receipt;
A statement from the fitness club, on the fitness club’s letterhead with authorized signature, indicating payment
was made;
A receipt for purchased items, with the fitness club’s name and address preprinted on the receipt, with items listed
and amount paid
14. Signature is required
I attest that the above information is accurate and complete. ________________________________________________
INTERNAL USE ONLY
Representative’s Name/Extension:
Corporate Receipt Date:
Please submit this form and all documentation to:
TUFTS HEALTH PLAN
MEMBER REIMBURSEMENT CLAIMS, PO BOX 9191
WATERTOWN, MA 02471-9191
18441-9/06
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business