Fillable Oxford Gym Reimbursement Form printable pdf download

Gym Reimbursement

Receive reimbursement for visiting the gym.

Stay in shape

To receive reimbursement for going to the gym, you must

take the following steps:

Starting or staying with an exercise routine isn’t always

easy. To help you stay motivated and achieve your fitness

You must complete a minimum of

1. Visit the gym –

goals, we provide reimbursement toward fitness center

50 visits per six-month period (you must wait until six

membership fees.

The reimbursement benefit is limited

months has passed even if you complete 50 visits

to you and your spouse or domestic partner

; no other

sooner than six months).

dependents are eligible. In order for your spouse or

Provide a copy of your current

2. Send paperwork –

domestic partner to be eligible for this benefit, he or she

gym bill, showing the monthly cost of your membership,

must also be enrolled in an Oxford product.

along with a brochure that outlines the services the

Selecting a gym

facility offers.

To receive reimbursement, you must participate in a gym

Fill out the Gym Reimbursement

3. Complete form –

and/or program that promotes cardiovascular wellness.

Form on the reverse side. You may also obtain additional

Memberships in sports clubs, country clubs, weight loss

forms from your benefits administrator, from our web site

clinics, spas, or other similar facilities will not be reimbursed.

w w w w w w . . o o x x f f o o r r d d h h e e a a l l t t h h . . c c o o m m , or by calling Customer Service

For a gym to be considered eligible, it must provide at

number on your Oxford ID Card. Please make sure a

least two pieces of equipment or activities that promote

representative from your gym signs the form.

cardiovascular wellness from the following list:

Submit the Gym Reimbursement Form to:

4. Mail form –

• stationary bicycle

Oxford

• treadmill

P.O. Box 7082

• elliptical crosstrainer

Bridgeport, CT 06601

• group exercise

• squash/tennis/racquetball courts

Gym Reimbursement Form

• stepper

To be eligible for reimbursement, you must complete the

• rowing machine

information below and send the following three items to:

• walking/running group

O O x x f f o o r r d d

• pool

P P . . O O . . B B o o x x 7 7 0 0 8 8 2 2

How much can I get reimbursed?

B B r r i i d d g g e e p p o o r r t t , , C C T T 0 0 6 6 6 6 0 0 1 1

1. This reimbursement form with 50 visits completed

Depending on your plan, Oxford offers subscribers up to

a $200 reimbursement per six-month period; covered

within a six-month period.

spouses or domestic partners

receive up

2. A copy of a bill from your gym, showing the monthly

to a $100 reimbursement per six-month period.

cost of your membership.

3. A copy of the gym’s brochure outlining the services

provided.

This level of reimbursement is not available to Members of all groups and is not available to Connecticut groups. Check your Certificate of Coverage to determine eligibility for this reimbursement.

Oxford subscribers and covered spouses/domestic partners will receive the lesser of their corresponding reimbursement amount or the facility membership fee per six-month period.

Reimbursement for domestic partners is limited to Members of groups that have purchased domestic partners coverage. Oxford Members and their spouses/domestic partners must

be covered Oxford Members for the entire six-month period to receive reimbursement.

8904 R2

Oxford Gym Reimbursement Form

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