Tufts Navigator Fitness – Fill Out and Use

GIC 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 club rebate, you must complete four consecutive months of membership in Tufts Health Plan and at a qualified fitness center each year you apply.

You will have 24 months from the date you incurred your fitness club fees to submit your request for the fitness rebate of up to $150. The rebate applies one time per family , one time per year. The rebate is paid to the Tufts Health Plan subscriber after fitness center fees are paid.

1. Member’s Name (Please print in capitals)

________________________________________________________________________

Last

First

MI

2.Member’s Tufts Health Plan ID #

3.Proof of payment through one of the following:

Please indicate which one of the following forms of proof of payment you are including with this form:

qAn itemized receipt from the fitness club, showing the dates of membership and dollar amounts paid

qCopies of receipts for fitness club membership dues

qA credit card statement or receipt

qA statement from the fitness club on the fitness club’s letterhead, with an authorized signature, indicating payment was made

In addition, you must include a statement from your fitness club confirming your membership for four consecutive months.

4. Member signature is required

I attest that the above information and enclosed proof of payment are accurate and complete.

______________________________________________________________

(GIC Member Signature)

5. Please submit this form and all documentation to:

Tufts Health Plan

GIC Fitness Claims

705 Mt. Auburn Street

Watertown, MA 02472-1508

Please do not staple any materials to this form.

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