Tufts Navigator Fitness PDF Details

Encouraging a healthy lifestyle while offering financial incentives, the Tufts Navigator Fitness form represents an innovative approach to wellness benefits. Through this program, eligible members can receive significant rebates on their fitness-related expenses, ensuring both individual and family members can save money while staying in shape. The form outlines two primary offers: reimbursement of one month's gym membership fee or up to $200 per benefit year towards fitness center memberships, with the provision for an additional $150 per family under certain plans. Eligibility criteria require a minimum consecutive four-month membership with both the gym and Tufts Health Plan within the benefit year. Importantly, the fitness centers must provide comprehensive physical fitness programs excluding services like personal training or at-home exercise equipment. A wide range of group exercise classes, including, but not limited to, Pilates, Zumba, and yoga, qualify for the rebate, though there are notable exclusions such as classes held in residential settings. Submission processes for the rebate are user-friendly, with options for online or mail applications, and must be accompanied by detailed proof of payment to ensure integrity and compliance. This form not only facilitates better physical health outcomes but also represents a thoughtful integration of health insurance benefits with proactive wellness initiatives.

QuestionAnswer
Form NameTufts Navigator Fitness
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesAuburn, itemized, capitals, incurred

Form Preview Example

FITNESS

REWARDS

Stay in Shape and Save

Get Money Back On Your Fitness Membership

Members can get reimbursed for one of the following options, whichever has the greater value:

•The cost of one month of individual or family fitness center membership per benefit year, or

•Fitness center membership costs up to a maximum of $200 per benefit year

This benefit applies to most Massachusetts (small group) and individual plans and is available upon renewal in 2022. You may confirm your fitness benefit by viewing your health plan coverage in your secure member account, visit mytuftshealthplan.com.

Rebate Rules:

1.You’re eligible for the rebate once you’ve been a member of Tufts Health Plan and the gym for at least 4 consecutive months in the applicable benefit year.

2.The fitness center must offer cardio and strength-training machines and other programs for improved physical fitness. The rebate does not include martial arts centers, gymnastics centers, country clubs, or pool-only centers, sports teams and leagues, social clubs and tennis clubs, personal trainers, sports coaches, or the purchase of personal or at-home exercise machines.

3.Exercise classes include, but are not limited to: Pilates, Zumba, yoga, aerobics, online fitness classes, and kickboxing. In-person classes held in a residential setting or dance classes are not included.

Tufts Health Plan will pay up to the reimbursable amount based on your plan.

GET YOUR REBATE

Submit your rebate form online at: mytuftshealthplan.com under the Forms tab. Or, you can mail in the rebate form on the reverse side.

REBATE FORM ON BACK

699210935-SG-0921

FITNESS

REWARDS

Stay in Shape and Save $150

Get Money Back On Your Fitness Membership

•$150 per family, per benefit year for fitness center membership fees and/or exercise classes

This benefit applies to most Massachusetts and Rhode Island (large group) plans and is available upon renewal in 2022. You may confirm your fitness benefit by viewing your health plan coverage in your secure member account, visit mytuftshealthplan.com.

Rebate Rules:

1.You’re eligible for the rebate once you’ve been a member of Tufts Health Plan and the gym for at least 4 consecutive months in the applicable benefit year.

2.The fitness center must offer cardio and strength-training machines and other programs for improved physical fitness. The rebate does not include martial arts centers, gymnastics centers, country clubs, or pool-only centers, sports teams and leagues, social clubs and tennis clubs, personal trainers, sports coaches, or the purchase of personal or at-home exercise machines.

3.Exercise classes include, but are not limited to: Pilates, Zumba, yoga, aerobics, online fitness classes, and kickboxing. In-person classes held in a residential setting or dance classes are not included.

Tufts Health Plan will pay up to the reimbursable amount based on your plan.

GET YOUR REBATE

Submit your rebate form online at: mytuftshealthplan.com under the Forms tab. Or, you can mail in the rebate form on the reverse side.

REBATE FORM ON BACK

699210935-LG-0921

MEMBER FITNESS REBATE FORM

You must complete all fields. Please print clearly. Retain a copy of all receipts and documents for your records. Please be sure to sign the form.

To qualify for the fitness rebate, you must complete 4 consecutive months of membership with Tufts Health Plan and 4 months with the gym in the applicable benefit year.

You will have 24 months from the date you paid your fitness club fees to submit your request for the fitness rebate. The rebate applies one time per family, one time per benefit year. The rebate is paid to the Tufts Health Plan subscriber after fitness costs are paid. We usually process reimbursements within 4 to 6 weeks of receipt. The rebate can be submitted multiple times until full reimbursement is met.

Member Information

Name (Last, First, Middle Initial): _______________________________________________________________________

Date of Birth: _______ / _______ / ________________

Tufts Health Plan Member ID Number

Fitness Center Information

Fitness Club Name: ___________________________________________________________________________________

Address: ____________________________________________________________________________________________

Telephone:__________________________________

Year(s) of fitness club membership:

Benefit Year 1: _______________________

Amount Paid: _______________________

 

Benefit Year 2: _______________________

Amount Paid: _______________________

Group Exercise Class Information (Check your benefits for this rebate)

Group Exercise Class Name: ___________________________________________________________________________

Address: ____________________________________________________________________________________________

Telephone:_________________________________

Year(s) of group exercise class(es):

Benefit Year 1: _______________________

Amount Paid: _______________________

 

Benefit Year 2: _______________________

Amount Paid: _______________________

Payment Information

Please include one of the following forms of proof of payment with this form:

•An itemized receipt from the fitness club and/or group exercise class, showing the dates of membership and dollar amounts paid

•A credit card statement or receipt indicating fitness club and/or group exercise class payment

•A statement from the fitness club’s and/or group exercise class’ letterhead, with an authorized signature, indicating payment was made

Signature Required

I attest that the above information is true and accurate, and the services were received and paid for in the amount requested as indicated above. I acknowledge that if any information on this form is misleading or fraudulent, my coverage may be canceled and I may be subject to criminal and/or civil penalties for false health care claims. I also understand that Tufts Health Plan may request any additional information it deems necessary to verify that services were received and payment was made. I understand that the fitness rebate may be considered taxable income.

Member Signature: _______________________________________________________________ Date: _________________________

PLEASE SUBMIT THIS FORM AND ALL DOCUMENTATION:

Online at:

 

 

Mail to:

 

 

 

 

Tufts Health Plan | Member Reimbursement Claims

or

mytuftshealthplan.com under the Forms tab

PO Box 9191, Watertown, MA 02471-9191

 

 

 

 

 

 

 

Please do not staple any materials to this form

 

 

 

699210935-LG-0921

How to Edit Tufts Navigator Fitness Online for Free

Managing documents along with our PDF editor is easier when compared with nearly anything. To edit itemized the file, there is nothing you have to do - just follow the actions down below:

Step 1: To begin, select the orange button "Get Form Now".

Step 2: You can now modify the itemized. You need to use our multifunctional toolbar to add, eliminate, and transform the text of the file.

Fill out the itemized PDF and enter the information for every single section:

portion of fields in REBATE

Enter the required data in REBATE FORM ON BACK area.

Filling out REBATE part 2

You will be requested for some fundamental details in order to complete the FITNESS REWARDS, Stay in Shape and Save, and Get Money Back On Your Fitness segment.

Filling out REBATE step 3

The segment allows you to point out the rights and obligations of all sides.

Completing REBATE step 4

Finish by looking at the next sections and preparing them as required: Member Information, Name Last First Middle Initial, Date of Birth, Tufts Health Plan Member ID Number, Fitness Center Information, Fitness Club Name, Address, Telephone, Years of fitness club membership, Benefit Year Amount Paid, Benefit Year Amount Paid, Group Exercise Class Information, Group Exercise Class Name, Address, and Telephone.

REBATE Member Information, Name Last First Middle Initial, Date of Birth, Tufts Health Plan Member ID Number, Fitness Center Information, Fitness Club Name, Address, Telephone, Years of fitness club membership, Benefit Year Amount Paid, Benefit Year Amount Paid, Group Exercise Class Information, Group Exercise Class Name, Address, and Telephone fields to fill out

Step 3: Click the "Done" button. Now it's easy to export the PDF file to your gadget. Aside from that, you can send it by electronic mail.

Step 4: Produce no less than several copies of the form to stay clear of any specific possible future issues.

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