Exercise Facility Reimbursement Form
Download a blank fillable Exercise Facility 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 Exercise Facility 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
1Exercise Facility Reimbursement Form
Oxford Health Plans • P.O. Box 7082 • Bridgeport, CT 06601-7082
To be eligible for reimbursement, you must complete the information below and send the following three
items to the above address.
1. This Exercise Facility Reimbursement form with 50 visits completed within a six-month period.
2. A copy of your current facility bill, showing the monthly cost of your membership.
3. A copy of the facility brochure outlining the services they provide.
Last name (Subscriber): ____________________________________
First name & MI:_________________________
Spouse’s last name: ________________________________________
First name & MI:_________________________
Subscriber’s ID Card number: ________________________________
Subscriber’s DOB (m/d/y):______/_______/_____
Spouse’s ID Card number: __________________________________
Spouse’s DOB (m/d/y):_______/_______/_____
Name of facilty where you are an active member:__________________________________________________________
Address of facilty:_____________________________________________________________________________________
Date
Signature of Facility
Date
Signature of Facility
Date
Signature of Facility
of Visit
Representative
of Visit
Representative
of Visit
Representative
_______________________________
______________________________
______________________________
1
18
35
_______________________________
______________________________
______________________________
2
19
36
_______________________________
______________________________
______________________________
3
20
37
_______________________________
______________________________
______________________________
4
21
38
_______________________________
______________________________
______________________________
5
22
39
_______________________________
______________________________
______________________________
6
23
40
_______________________________
______________________________
______________________________
7
24
41
_______________________________
______________________________
______________________________
8
25
42
_______________________________
______________________________
______________________________
9
26
43
______________________________
______________________________
______________________________
10
27
44
_____________________________
______________________________
______________________________
11_
28
45
______________________________
______________________________
______________________________
12
29
46
______________________________
______________________________
______________________________
13
30
47
______________________________
______________________________
______________________________
14
31
48
______________________________
______________________________
______________________________
15
32
49
_____________________________
______________________________
______________________________
16_
32
50
______________________________
______________________________
17
34
Phone ____________________________ Fax ___________________________
Facility employee signatures above constitute agreement that the facility promotes cardiovascular wellness for Members.
False statements will result in a denial of coverage.
My signature below affirms that all of the information listed above is full, complete, and true ,to the best of my knowledge.
____________________________________________________
____________________________
Employee/Applicant Signature
Date
OHP Subscriber Exercise Reimbursement Form
1721 - rev 6/00
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business