Oxford Gym Reimbursement Page 2
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1
2Gym Reimbursement Form
Substitutes for the gym reimbursement form
To be eligible for reimbursement, you must complete the
One of the following pieces of documentation may be
information below and send the following three items to:
used as a substitute for the Gym Reimbursement Form:
(Note: Your documentation must include a signature from
Oxford Health Plans,
a facility representative for verification purposes.)
P.O. Box 7082
Bridgeport, CT 06601
•
a photocopy of your fitness program card or your
records kept on file at the fitness center. An original
1. This reimbursement form with 50 visits completed
signature must appear on the photocopy (photocopied
within a six-month period.
signatures are not valid)
2. A copy of your facility’s bill, showing the monthly
•
a computer printout of your visits to the fitness center
cost of your membership.
•
receipts that indicate each time you have visited the
3. A copy of the facility brochure outlining the
fitness center, or
services provided.
•
verification from your employer that indicates your use
of the employer’s gym
Your Name: ____________________________________
This documentation should be mailed to: Oxford Health Plans,
P.O. Box 7082, Bridgeport, CT, 06601-7082, along with your
Oxford Member ID Number: ______________________
name and/or your spouse’s or domestic partner’s name,
Your Address: __________________________________
Oxford Member ID number, and current mailing address.
Date of visit:
Date of visit:
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50.
Name of Facility: ______________________________________ Facility Employee Signature: __________________
Facility employee signature above constitutes agreement that the facility promotes cardiovascular wellness. False
statements will result in a denial of reimbursement. My signature below affirms that all of the information listed
above is full, complete and true to the best of my knowledge.
Member Signature:
__________________________________ Date: ______________________________________
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