Harvard Pilgrim Fitness Reimbursement Form Page 2
Download a blank fillable Harvard Pilgrim Fitness Reimbursement 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 Harvard Pilgrim Fitness Reimbursement 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
2Harvard 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 health club and Harvard Pilgrim Health Care for at least four consecutive months in a calendar year.
• Once per calendar year, filed by March 31 of the following year, with all necessary receipts and health club contract.
• 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)
Social Security Number (at least last four digits)
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 – Health Club Information
(list all health clubs that you and/or your dependent(s) are submitting for reimbursement
listing the qualifying four consecutive months.)
Calendar Year
From: mm/dd/yyyy
Phone Number
$ Amount
To: mm/dd/yyyy
Club Name
City, State
(Area Code) xxx-xxxx
being claimed
From: ___ /___ /_______
To: ___ /___ /_______
From: ___ /___ /_______
To: ___ /___ /_______
From: ___ /___ /_______
To: ___ /___ /_______
Total number of documents
$
Total dollar amount being claimed
up to $150 per calendar year
Section D – Subscriber Certification
I certify that the information on the form and all supporting documents are complete, accurate and unaltered.
Subscriber’s Signature
Date
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business