Fillable Harvard Pilgrim Fitness Reimbursement Form printable pdf download

Harvard Pilgrim Fitness Reimbursement Form

Please read the instructions below, then proceed to fill out the Fitness Reimbursement Form.

Mailing Instructions

Please enclose the following:

Keep copies of all documentation before sending in your Fitness Reimbursement Form.

1. Copy of your health club membership agreement

2. Completed Fitness Reimbursement Form

3. Copy of receipts (cash/check/credit/electronic) for health club membership dues clearly documenting

your name and the health club name. Dues must equal or exceed amount being claimed.

Harvard Pilgrim Health Care

4. Mail to:

P. O. Box 9185

Quincy, MA 02269

Commonly Asked Questions and Answers

How do you qualify for a reimbursement?

• The employer of the subscriber (i.e., the person who holds the Harvard Pilgrim policy) must offer Harvard Pilgrim’s fitness

reimbursement program. Note: Reimbursement is not available to members enrolled through First Seniority, Nongroup,

Passport Connect and Health Plans, Inc.

• Health club membership must be for at least four consecutive months in length in a calendar year (beginning in January

of the current calendar year).

• Subscriber must be active, i.e., a current member of Harvard Pilgrim, at the time of Harvard Pilgrim’s receipt of

a complete fitness reimbursement form

• Current Harvard Pilgrim membership must be equal to or greater than four consecutive months in length with

the same employer group in a calendar year and must coincide with 4 months of gym membership.

When can you submit your Fitness Reimbursement Form?

Starting May 1 of the calendar year*

How does your health club qualify?

• A qualified, full-service health and fitness club is a facility with cardiovascular and strength-training equipment

and facilities for exercising and improving physical fitness.

• Facilities/programs that DO NOT qualify for reimbursement include: Martial arts centers, gymnastics facilities, classes,

country clubs, fees for personal trainers, tennis, aerobic or pool-only facilities, as well as sports teams and leagues.

How much can you claim for reimbursement?

• Reimbursement is up to $150 per calendar year (e.g., January–December) in total for health club membership dues

for subscriber and/or their dependents.

• Subscriber may receive fitness reimbursement only once for a calendar year.

What happens once you submit the Fitness Reimbursement Form?

• Reimbursement checks will be mailed and made payable to the Subscriber only at the Subscriber’s address of record.

No alternative address will be accepted.

• If you believe your current address is different than the address of record in Harvard Pilgrim’s systems, please contact us prior to

submitting your Fitness Reimbursement Form. In most cases we will update your address in our systems directly — in other cases,

when your employer submits transactions to us electronically, we will ask you to inform your employer of your address change.

• Please allow 6-8 weeks for processing.

*Certain employers will offer this program upon their annual enrollment/anniversary date. In these instances, you’ll be eligible four consecutive months after the

enrollment/anniversary date. For example: If your employer’s enrollment/anniversary date is July 1, 2007, eligibility to submit for reimbursement begins no earlier

than November 1, 2007 (as long as all other criteria is met, including being an active member).

This information refers to plans offered by Harvard Pilgrim Health Care and its affiliates, including

Harvard Pilgrim Health Care of New England and HPHC Insurance Company.

Fitness reimbursement program requirements are subject to change without notice.

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