Get Anthem Gym Reimbursement Form

Filling out the Anthem Gym Reimbursement Form online can be a straightforward process when you know what to do. This guide provides detailed, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Anthem Gym Reimbursement Form online

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Fill in the member’s name in the designated field, clearly indicating the last name, first name, and middle initial.
3. Enter the member’s date of birth by selecting the month, day, and year from the dropdown options or filling them in manually.
4. Indicate the member's sex by selecting either male or female.
5. Provide the group name and division number associated with your employer, ensuring accuracy.
6. If the subscriber is different from the member, fill in the subscriber's name using the same format as in step 2.
7. Complete the subscriber's address by entering the street, city, state, and zip code. Additionally, indicate if the address is new.
8. Fill in the telephone number of the subscriber for contact purposes.
9. In the workout period section, specify the start and end dates of the fitness activities you wish to reimburse.
10. Enter the amount paid by the member for the fitness center dues.
11. Provide the date you are completing the form.
12. Sign the form yourself, confirming that the information is accurate. Additionally, have a fitness center employee sign the bottom of the form.
13. Attached required documentation including the Fitness Reimbursement Program Log Card or fitness center printout and original receipts.
14. Once all sections are completed and documents are attached, submit the form to the claims department using the provided address.

Complete your Anthem Gym Reimbursement Form online today to ensure you receive your fitness reimbursement.