Get Gym Reimbursement Form 2017

Completing the Gym Reimbursement Form 2017 online can streamline your process of requesting reimbursement for gym and health club membership dues. This guide will provide clear, step-by-step instructions to assist you in filling out the form accurately and efficiently.

Follow the steps to successfully complete your Gym Reimbursement Form 2017

1. Click ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. Fill out the member information section using black or blue ink only. Provide your full name (Last, First, Middle Initial), address (including street, city, state, and ZIP code), date of birth, and contact number. Include your Inter Valley Health Plan Member ID number for identification.
3. In the gym/health club information section, list the name of the facility and its complete address. This ensures that your reimbursement is linked to the correct service provider.
4. Move to the payment information section. Indicate the form of proof of payment you are attaching, such as an itemized receipt from the gym, a credit card statement, or a statement from the gym’s letterhead with an authorized signature.
5. Specify the monthly reimbursement requested in the designated fields for each month of the year 2017. Remember that the maximum allowance is $25 per month.
6. Be sure to sign and date the form in the signature required section. Your signature confirms that the information provided is accurate and that you understand the consequences of false claims.
7. After completing all sections, review the form for accuracy, attach any necessary documentation, and submit it by mailing it to Inter Valley Health Plan, Claims Department/Gym, P.O. Box 6002, Pomona, CA 91769-6002.

Ensure you complete your Gym Reimbursement Form 2017 online today for a hassle-free submission process.