United Healthcare Gym Reimbursement Form Details

The Oxford gym reimbursement form is a great way to get some of your hard-earned money back. If you're a student at the university, you can use the form to receive up to £10 per month in reimbursements for your membership fees.

This article holds specifics of oxford gym reimbursement. Prior to fill out the form, it is worth reading a little more about it.

QuestionAnswer
Form NameOxford Gym Reimbursement
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesoxford health sweat equity, oxford health gym reimbursement form, sweat equity program, unitedhealthcare oxford gym reimbursement

Form Preview Example

Gym Reimbursement

The only thing better than staying in shape is getting reimbursed for it.

Healthier members are happier members.

Starting or staying with an exercise routine isn’t always easy. To help you stay motivated and achieve your itness goals, we provide reimbursement toward itness center membership fees.1 You can get reimbursed for going to the gym an average of two-to-three times per week. We know that staying with an exercise routine isn’t always easy, and this can help you stay motivated and healthy.

Note: his reimbursement is not available to all Oxford plan members, including members of any Connecticut plan, and some New York and New Jersey plans. Please refer to your Certiicate of Coverage, Summary Plan Description or other governing member document that applies to your plan for beneit availability.

It’s easy. First, select a gym.

To receive reimbursement, you must participate in a gym and/or program that promotes cardiovascular wellness. (Memberships in sports clubs, country clubs, weight loss clinics, spas or other similar facilities are not eligible.) For a gym to be considered eligible, it must provide at least two pieces of equipment or activities that promote cardiovascular wellness from the following list:

• elliptical cross-trainer

• stationary bicycle

• group exercise

• step machine/climber

• pool

• treadmill

• rowing machine

• walking/running group

• squash/tennis/

 

racquetball courts

 

How much can you get reimbursed?

Please check your beneits documents or check with your beneits administrator to determine how much you (and your spouse or domestic partner) may be reimbursed.2

he reimbursement period begins on the date of your initial visit to the gym and ends six months from that date. Subsequent reimbursement periods begin one day after your previous reimbursement period ended.3

You should follow the steps below to receive reimbursement for your fitness participation:

1. Visit the gym – You must complete a minimum of 50 visits per six-month period. Reimbursements will not be issued until six months have passed, even if 50 visits are completed sooner than six months.

2. Collect paperwork – You need to collect three things: a copy of your current gym bill, showing the monthly cost of your membership; proof of payment for each of the six months you are submitting for reimbursement (i.e., credit card statement, payroll deduction, automatic bank withdrawal, etc.);4 and a copy of the brochure that outlines the services the gym ofers.

3. Complete the form – Fill out and submit a Gym Reimbursement Form, which is shown on the reverse side of this page. Remember to provide the dates of your gym visits completed within the six-month period for which you are making a claim. Also, a representative from your gym must sign the form. You can get extra forms from your beneits administrator, from our website oxfordhealth. com or by calling Customer Service at the telephone number on your health plan ID card.

4. Mail everything – he Gym Reimbursement Form, along with a copy of your current gym bill, proof of payment and a copy of the gym’s brochure, should be submitted within six months (180 days) to the following address:

Oxford Gym Reimbursement

P.O. Box 29130

Hot Springs, AR 71903

Call the telephone number on your health plan ID card

Important: Please complete the form in its entirety, or the processing of your claim may be delayed or denied. Please complete one form per member, for each six-month period for which you are making a claim.

1Check your Certiicate of Coverage, Summary Plan Description or other governing member document to determine eligibility for this reimbursement.

2he reimbursement beneit is limited to you and your spouse or domestic partner; no other dependents are eligible. For your spouse or domestic partner to be eligible for this beneit, he or she must also be enrolled in an Oxford product. Reimbursement amounts may vary depending upon your plan. Please refer to your Certiicate of Coverage/health beneits plan documents to conirm your policy’s beneit.

3

Please refer to your Certiicate of Coverage, Summary Plan Description or other governing member document to conirm your policy’s beneit and for applicable iling deadlines. Claim must be iled upon

 

completion of the six-month period being submitted in order to obtain reimbursement.

4

On your proof of payment, please be sure to cross out your personal account identiication information and other information not relevant to your gym payment so it is not legible.

Gym Reimbursement Form

Member name: __________________________________________ Member address: ______________________________

Oxford member ID number: ________________________________ Date of birth: _________________________________

Six-month period requested: Start date: _________________________ End date: ________________________________

Dates of your 50 gym visits*:

1.

18.

35.

 

 

 

 

 

2.

19.

36.

 

 

 

 

 

3.

 

20.

 

37.

4.

21.

38.

 

 

 

 

 

5.

22.

39.

 

 

 

 

 

6.

 

23.

 

40.

7.

24.

41.

 

 

 

 

 

8.

25.

42.

 

 

 

 

 

9.

 

26.

 

43.

10.

27.

44.

 

 

 

 

 

11.

28.

45.

 

 

 

 

 

12.

 

29.

 

46.

13.

30.

47.

 

 

 

 

 

14.

31.

48.

 

 

 

 

 

15.

 

32.

 

49.

16.

33.

50.

 

 

 

 

 

17.

34.

 

 

 

 

 

 

 

*As a substitute for illing in the dates of your 50 gym visits on this form, you may submit one of the pieces of documentation that are listed below as an attachment to this form. Your documentation must include a signature from a gym representative for veriication purposes.

A computer printout of your visits to the itness center;

Receipts that indicate each time you have visited the gym; or

Veriication from your employer that indicates your use of the employer’s gym.

Name of facility: ________________________________________ Facility employee’s signature: _____________________

Facility employee’s signature above constitutes agreement that the facility promotes cardiovascular wellness for members. False statements will result in the

denial of reimbursement. My signature below airms that all of the information listed above is full, complete and true to the best of my knowledge.

Member signature: _________________________________________________________ Date: ______________________

If you have any questions regarding gym reimbursement, please call Customer Service at 1-800-444-6222.

Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc. and Oxford Health Plans (NJ), Inc.

Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

MS-12-982 10/12 8904 R6 © 2011 Oxford Health Plans LLC. All rights reserved.