Gym Reimbursement Form
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1Gym Reimbursement Form
Mailing Adress: P.O. Box 7082, Bridgeport, CT. 06601-7082; Phone: 1-800-444-6222
Important:
Please complete this form in its entirety, or the processing of your claim may be delayed.
To be eligible for reimbursement, you must complete the information below and send the following three items to the
above address:
1. This 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 brochure that outlines the services the facility offers.
About Your Benefit:
You are eligible to receive one reimbursement per six-month period in which 50 visits are completed. The reimbursement
period commences on the date of your initial visit to the gym and ends six months from that date. Subsequent
reimbursement periods begin one day after your previous reimbursement period ended.
For example, if your six-month period spans from 2-10-05 to 8-10-05 and 50 visits are completed by 5-30-05, visits completed
between 5-31-05 and 8-10-05 do not count towards the next six-month period. The next six-month period would begin on
8-11-05.
Your Name: ___________________________________________________________________________
Your Oxford Member ID Number: _______________________________________________________
Address: ______________________________________________________________________________
Date of visit:
Date of visit:
Date of visit:
1. _____________________________________
18. ____________________________________
35. ____________________________________
2. _____________________________________
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36. ____________________________________
3. _____________________________________
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4. _____________________________________
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5. _____________________________________
22. ____________________________________
39. ____________________________________
6. _____________________________________
23. ____________________________________
40. ____________________________________
7. _____________________________________
24. ____________________________________
41. ____________________________________
8. _____________________________________
25. ____________________________________
42. ____________________________________
9. _____________________________________
26. ____________________________________
43. ____________________________________
10. ____________________________________
27. ____________________________________
44. ____________________________________
11. ____________________________________
28. ____________________________________
45. ____________________________________
12. ____________________________________
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13. ____________________________________
30. ____________________________________
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14. ____________________________________
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15. ____________________________________
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49. ____________________________________
16. ____________________________________
33. ____________________________________
50. ____________________________________
17. ____________________________________
34. ____________________________________
Name of facility: ______________________ Facility employee signature: ________________________
Facility employee signatures above constitutes agreement that the facility promotes cardiovascular wellness for Members.
False statements will result in the 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: _______________________
MS-04-181
1721 Rev 7
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