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Get Unicare EC729 2018

Page 1 Fitness Club Reimbursement Form 1. Enrollee name Last First MI 2. Enrollee address 3. Member ID from UniCare ID card 4. Enrollee birth date 5. Member name if different from enrollee 6. Name of fitness club 7. Member s relationship to enrollee 8. Requested reimbursement amount 9. What months are you requesting reimbursement for Example 7/2018 through 12/2018 Write your member ID on all paperwork. Send this form and your proof of payment to UniCare State Indemnity Plan PO Box 9016 Andover MA 01810-0916 See page 1 for instructions. Upon proof of payment the reimbursement is paid to the Plan enrollee subscriber. What types of fitness clubs qualify Eligible for reimbursement Not eligible for reimbursement Health clubs and gyms that have cardio / strength-training machines as well as other programs for improved physical fitness Beach clubs Country clubs Dance classes/studios Exercise machines Gymnastics centers Martial arts centers Personal trainers Sports coaches Sports teams/leagues Tennis clubs Yoga classes What information do I need to provide A completed copy of the Fitness Club Reimbursement form page 2 Proof of payment at least one of the following Itemized receipts from the fitness club that shows how much you paid and for what period of time Copies of receipts for fitness club membership dues Credit card statement or receipts Statement from fitness club showing that payment was made statement must be on the club s letterhead and have an authorized signature What else do I need to know Write your UniCare member ID number prominently on all the receipts and documents that you are sending to UniCare. UNICARE STATE INDEMNITY PLAN FITNESS CLUB REIMBURSEMENT For UniCare State Indemnity Plan members What is the fitness club reimbursement The Plan offers a 100 reimbursement benefit toward membership at a fitness club. Keep copies of all your receipts and documents for your records. Send the completed reimbursement form and copies of your payment receipts to the address shown in the box on page 2. We recommend that you send proof of payment for the entire amount instead of making several requests for lesser amounts. If you have any other questions call UniCare Member Services 833-663-4176 for Basic PLUS and Community Choice members or 800-442-9300 for Medicare Extension members. Reimbursement form is on page 2 ec729 06/18 Claims are administered by UniCare Life Health Insurance Company. Enrollee birth date 5. Member name if different from enrollee 6. Name of fitness club 7. Member s relationship to enrollee 8. Requested reimbursement amount 9. What months are you requesting reimbursement for Example 7/2018 through 12/2018 Write your member ID on all paperwork. Send this form and your proof of payment to UniCare State Indemnity Plan PO Box 9016 Andover MA 01810-0916 See page 1 for instructions. Keep copies of all your receipts and documents for your records. Send the completed reimbursement form and copies of your payment receipts to the address shown in the box on page 2. We recommend that you send proof of payment for the entire amount instead of making several requests for lesser amounts. .

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