Follow the steps to complete your reimbursement form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your personal information in the designated fields. Fill in your last name, first name, middle initial, mailing address, date of birth, HPI Member ID, email address, primary phone number, and ZIP code.
3. Indicate the participant for whom you are requesting reimbursement by checking the appropriate box (Employee, Spouse/Partner, Child/Other Dependent, Ex-Spouse). If it is for someone other than yourself, fill in their last name, first name, date of birth, relationship to you, and gender.
4. Provide the weight loss program information by filling in the start and end dates of attendance. Use the MM/DD/YYYY format for both dates.
5. Enter the name of the weight loss program, the address including city and state, and the program's contact phone number, including the area code.
6. Fill in the total amount you are claiming for reimbursement. Ensure this amount is accurate to avoid delays.
7. Certify that the information provided is complete and accurate by signing in the designated area and including the date signed.
8. Once you have filled out all sections, ensure you attach all necessary documentation, such as receipts and the weight loss program agreement form. Save your changes and download, print, or share the completed form as needed.

Complete your MA HPI Weight Loss Program Reimbursement Form online to expedite your claim process.