Fitness Benefit Form - Blue Cross Blue Shield Of Massachusetts

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FITNESS BENEFIT FORM
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
PLEASE PRINT ALL INFORMATION CLEARLY
SUBSCRIBER INFORMATION
(person in whose name coverage is held)
Identification Number (including alpha prefix)
Subscriber’s Last Name
First Name
Middle Initial
Address—Number and Street
City
State
Zip Code
Employer’s Name
MEMBER INFORMATION
MEMBER INFORMATION
Member’s Last Name
First Name
Middle Initial
Date of Birth: Mo. Day Year
Mailing Address (if different from subscriber’s)
Number and Street
City
State
Zip Code
Gender
Claimant is (check one:)
1.
1.
3.
Male
Subscriber (coverage holder)
Child (age 21 or younger)
2.
2.
4.
Female
Spouse (of coverage holder)
Handicapped Dependent
WHEN TO SUBMIT THIS FORM:
•
After you have been a member of a health club and Dental Blue Healthy Supplement for at least 4 months in a calendar year.
•
Once per calendar year, filed by March 31 of the following year.
HEALTH CLUB INFORMATION REQUIRED
(Attach 8.5" x 11" photocopies of dated, paid health club receipts and your health club agreement/contract.)
Name and Address of Health Club
Questions?
1-800-433-7766.
For further information, call us at
TOTAL NUMBER OF RECEIPT COPIES ATTACHED: ________ TOTAL AMOUNT SUBMITTED: $ ____________________
CERTIFICATION AND AUTHORIZATION (This form must be signed and dated below.)
I authorize the release of any information to Blue Cross and Blue Shield of Massachusetts, Inc., about my health club
membership. I certify that the information provided in support of this submission is complete and correct, and that I
have not previously submitted for these services.
Subscriber’s/Member’s Signature: ___________________________________________________________ Date: __________________________
Please tear off, fold, and mail this form (including copies of paid receipts) to:
Blue Cross Blue Shield of Massachusetts
Federal Employee Program Claims Department
PO Box 55380
Boston, MA 02205-8338
11

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