Get Gym Reimbursement Form - Careconnect

Filling out the Gym Reimbursement Form - CareConnect online is a straightforward process that can help you receive reimbursement for your fitness membership. This guide will walk you through each section of the form, ensuring you provide all necessary information accurately.

Follow the steps to successfully complete your Gym Reimbursement Form.

1. Click the ‘Get Form’ button to obtain the Gym Reimbursement Form and open it in your preferred online editor.
2. Begin by entering your member information. Fill in your last name, first name, middle initial, member ID number, and birth date using the format mm/dd/yy. Provide your street address, city, state, zip code, and phone number.
3. If the patient’s name differs from yours, please fill in their name and birth date as well to ensure clarity.
4. Next, move to the service information section. Indicate the start and end date of the reimbursement period, and fill in the place of service along with any applicable diagnosis codes.
5. Provide details about your fitness facility. Include the name and address of the facility and the total membership fee you paid. This fee should clearly reflect what you are seeking reimbursement for.
6. Document your visits in the section provided. Use the designated lines to indicate the dates you visited the gym, ensuring that you meet the minimum of 50 visits within the six-month period.
7. Ensure to collect and attach your gym bill, proof of payment, and a record of gym visits along with this completed form.
8. Before submitting, review your completed form to ensure all information is accurate and legible. Incomplete information may lead to delays or denial of your claim.
9. Once you have finalized your form, save any changes, download a copy for your records, print a physical copy if needed, and prepare to send it along with your attachments to the provided CareConnect address.

Start your Gym Reimbursement Form - CareConnect online today to take advantage of your fitness reimbursement benefits!