Reimbursement And Information Order Form - Blue Cross printable pdf download

Healthy Lifestyles

Reimbursement

and Information Order Form

To request your reimbursement, provide all the information requested on this form and attach required documentation,

such as receipts, membership contracts, and enrollment forms. To order free informational materials, mark the check

boxes next to the items you want to receive.

For additional reimbursement forms, you may copy this form, download it from , or call

Healthy Lifestyles at the number listed at the bottom of this page.

Name: _____________________________________________________________________________________

Date of birth:

______ /_____ /_____ Email: ___________________________________________________

Address: ___________________________________________________________________________________

City: _________________________________________ State: _______________________ZIP: ____________

Health plan ID # (found on your member ID card): ________________________________________________

Telephone (day): _________________________ Telephone (evening): _______________________________

Reimbursement request

I have completed all requirements for the programs indicated

below and have attached the required documentation. Please

Information request

process my reimbursement for: (Check all that apply.)

Please send me a free copy

Fitness Program

Parenting class

of the following materials:

Baby’s due date: ___/___/___

(Check all that apply.)

Healthy Weight, Healthy You

Breast pump

Program start date: ___/___/___

Adoption booklet

Baby’s due date: ___/___/___

Tobacco Cessation

Lactation consultant

Clearing the Air booklet

Program start date: ___/___/___

Baby’s due date: ___/___/___

First-aid, safety, or CPR class

Stress management CD

Delivery date: ___/___/___

Course completion

date: ___/___/___

Wellness Guidelines

Bike helmet

Total amount of enclosed receipt(s): $

__________________________________________

Independence Blue Cross

Mail your form and

Healthy Lifestyles Program

documentation to:

1901 Market Street, P.O. Box 41880

Philadelphia, PA 19101-9131

Questions?

Call Healthy Lifestyles at 1-800-ASK-BLUE, TDD 1-888-857-4813, Monday through Friday, 8 a.m. to 5 p.m. ET.

Incentive programs or health care services described in this booklet as part of Healthy Lifestyles are contingent on a member being eligible for coverage at the time of

participation and subject to the terms, limitations, and exclusions of his or her health care beneﬁts program. Healthy Lifestyles programs are value-added programs and

services; they are not beneﬁts under the health care plan that you purchased and are therefore subject to change without notice.

You must be a member of an Independence Blue Cross health plan at the time of enrollment and program completion in order to receive your reimbursement. Co-payments,

deductibles, and co-insurance fees are not eligible for reimbursement. Reimbursement will not be issued if information is falsiﬁed.