Fitness Reimbursement Form at a glance
What it is: The Fitness Reimbursement Form is for use when you are eligible for fitness reimbursement through your employer or individual plan.
Who signs: After all sections have been completely filled out and signed by the subscriber.
Where and when to file: Submit once per calendar year, by March 31 of the following year, with all necessary receipts or proof of payment. Mail to: Harvard Pilgrim Health Care P. O. Box 9185 Quincy, MA 02269.
To be filled out by Harvard Pilgrim Health Care SUBSCRIBER only.
What to bring and attach to Fitness Reimbursement Form
Please enclose a copy of your health/fitness membership agreement.
Please enclose the completed Fitness Reimbursement Form.
Please enclose receipts showing that you paid for at least four months in a calendar year for membership or subscription fees (must show your name and the facility or program name). Fees must equal or exceed amounts being claimed.
A filled-in Fitness Reimbursement Form example: a subscriber claims a gym membership
How to fill out Fitness Reimbursement Form, box by box
Section A - Subscriber Information
Under Section A, Subscriber Information (person who holds coverage), enter the Harvard Pilgrim ID Number, Subscriber's Last Name, First Name, Middle Initial, Date of Birth (mm/dd/yyyy), Address, City, State, ZIP Code, Daytime Phone (area code) xxx-xxxx, Company Name (Employer) and Subscriber's Email.
Section B - Subscriber and/or Member Information for Reimbursement
Under Section B, Subscriber and/or Member Information for Reimbursement, enter on each line the Harvard Pilgrim ID Number, Last Name, First Name and Date of Birth (mm/dd/yyyy).
Section C - Fitness Program Information
Under Section C, Fitness Program Information, list all health and facility memberships that you and/or your dependent(s) are submitting for reimbursement spanning the qualifying four months.
For each one enter Calendar Year from: mm/dd/yyyy to: mm/dd/yyyy, Facility or Program Name, City, State, Phone Number (Area Code) xxx-xxxx and $ Amount being claimed, and ATTACH DOCUMENTATION.
Section D - Fitness Tracking Device Information
Under Section D, Fitness Tracking Device Information, list the brand, i.e., Apple Watch, Fitbit, Garmin, Nike, Samsung Gear, etc. Not all members are eligible for this reimbursement; see instructions on page 2.
Small group or individual plans in MA allow up to $150 total for fitness membership fees and fitness trackers (checked November 8, 2026).
Enter the Purchase Date, Tracking Device Brand and $ Amount being claimed, and ATTACH RECEIPT.
Totals
Enter the Total number of documents and the Total dollar amount being claimed.
Section E - Subscriber Certification
Under Section E, Subscriber Certification, you certify the information on the form and all supporting documents are complete, accurate and unaltered.
You will attempt, in good faith, to regularly use your fitness services for which you are being reimbursed.
Enter the Subscriber's Signature and the Date.
More rules for Fitness Reimbursement Form
Reimbursement checks will be mailed and made payable only to the Subscriber only at the Subscriber's address of record.
No other address will be accepted. If you believe your current address is different from the address on file, please call the Member Services number on the back of your ID card before you submit the form.
Validation is subject to approval by Harvard Pilgrim.
Family plans, other plans and what qualifies
You are on a family plan
When eligible, up to two members on a family plan can be reimbursed for up to $150 each, for a maximum reimbursement of $300 (checked November 8, 2026).
Any combination of subscriber, spouse or dependent is eligible for reimbursement.
Your plan has one covered member
For plans with one covered member, the maximum reimbursement amount is $150 (checked November 8, 2026).
Your plan is different
Some members may be eligible for a different reimbursement amount based on their health plan. Check with your employer or contact Member Services for eligibility and reimbursement amount.
What qualifies for fitness reimbursement
Full-service health/fitness facilities that have cardiovascular and strength-training equipment qualify, as well as facilities for exercising and improving physical fitness.
Fitness studios/facilities that offer yoga, Pilates, Zumba, aerobic/group classes, indoor cycling/spinning classes, kick-boxing, CrossFit, strength training, tennis, indoor rock climbing and personal training (taught by a certified instructor).
What qualifies for fitness reimbursement: virtual fitness subscriptions.
Not eligible for reimbursement: fees you pay for group classes or personal training outside of a fitness facility/studio, and health club initiation fees or costs that you pay for instructional dance studios, country clubs, social clubs (such as ski, riding or hiking clubs), spas, gymnastics facilities, martial arts schools, pool-only facilities, road race fees, sport camps, ski passes, sports teams or leagues, and school sports athletic user fees.
Before you go
Please use blue or black ink and print all information clearly.
After you have been a member in qualified fitness program and Harvard Pilgrim Health Care for at least four months in a calendar year.
Starting on May 1 of the current calendar year and when you have met the above-stated criteria on page 1 (What qualifies for fitness reimbursement).
Common questions about Fitness Reimbursement Form
Who signs it?
After all sections have been completely filled out and signed by the subscriber.
Is there a deadline?
Submit once per calendar year, by March 31 of the following year, with all necessary receipts or proof of payment. Some small group and individual plans have until December 31 of the following calendar year to submit for reimbursement. Please allow up to 8 weeks for processing.
Where do I file it?
Mail to: Harvard Pilgrim Health Care P. O. Box 9185 Quincy, MA 02269. Want your reimbursement faster? Submit your request online at harvardpilgrim.org/fitnessreimbursement.
Sources
[1] Fitness Reimbursement Form (CW777174103-11/21), Harvard Pilgrim Health Care (the Official source link on this page).