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Get Harvard Pilgrim Fittness Reimbursement Form
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How to fill out the Harvard Pilgrim Fitness Reimbursement Form online
Completing the Harvard Pilgrim Fitness Reimbursement Form online streamlines the process of obtaining reimbursement for your health club membership fees. This guide provides clear, step-by-step instructions on how to effectively fill out the form, ensuring you have all necessary information ready for submission.
Follow the steps to successfully complete your reimbursement form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter your subscriber information in Section A. Provide your Harvard Pilgrim ID number, last name, first name, date of birth, and the last four digits of your Social Security number. Include your current address, daytime phone number, company name, state, ZIP code, and your email address.
- In Section B, input the reimbursement information for yourself and/or dependents. Provide the Harvard Pilgrim ID number, last name, first name, and date of birth for each individual included.
- Complete Section C with the health club information. List all health clubs where you and/or your dependents are submitting for reimbursement. Include the club name, its city and state, phone number, and the total dollar amount being claimed, ensuring it does not exceed $150 per calendar year.
- In Section D, read the subscriber certification statement carefully. By signing, you affirm that all provided information is accurate and complete. Add your signature and the date to finalize this section.
- Once you have filled out all sections of the form, ensure that all documentation is attached, including copies of your health club membership agreement and at least four months of receipts. Save any changes made, then download or print the completed form for mailing.
Complete your Harvard Pilgrim Fitness Reimbursement Form online today for a quicker reimbursement experience.
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The timely filing limit for Harvard Pilgrim claims is typically 180 days from the date of service. If you submit your claim after this period, it may be denied. To avoid the hassle, ensure you complete your Harvard Pilgrim Fitness Reimbursement Form and submit it promptly.
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