Request Form/Log and proof of payment to: ExerciseRewards, P.O. Box 509117, San Diego, CA 92150-9117 Please keep a copy of your fitness facility agreement. We may ask you for a copy later. Failure to submit this form completed with all required information may result in a denial. Last Name First Name M.I. Date of Birth Health Plan ID Fitness Facility Informat.
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How to fill out the Fitness Facility Member Verification Form online
The Fitness Facility Member Verification Form is essential for users seeking reimbursement for fitness facility fees. This guide provides straightforward instructions tailored to help users complete the form accurately and efficiently online.
Follow the steps to successfully fill out the Fitness Facility Member Verification Form.
- Press the ‘Get Form’ button to obtain the form and open it in your online editor.
- Begin by entering your full name in the designated fields, including your last name, first name, and middle initial.
- Provide your date of birth and health plan ID in the appropriate fields to ensure proper identification.
- Fill in the fitness facility information by writing the facility's name, address, city, county, state, and ZIP+4 code.
- Indicate the type of arrangement you have with the facility by selecting the relevant option and providing additional explanations if necessary.
- Specify your membership type by choosing between individual or family membership. If you select family membership, list the names of family members in the provided spaces.
- Input the amount you paid for your membership, alongside the membership term details. Specify the start date and end date as applicable.
- Under the fitness facility attestation section, the fitness facility representative should fill in their name and signature, as well as the date of attestation.
- Review all the entered information for accuracy and completeness before saving the changes to the completed form.
- Finally, download, print, or share the completed form as required, and ensure you submit it with your ExerciseRewards Reimbursement Request Form/Log and proof of payment.
Complete your Fitness Facility Member Verification Form online today for a smooth reimbursement process.
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