Unicare Fitness Form PDF Details

In today's health-conscious society, staying fit and active is more important than ever. For members of the UniCare State Indemnity Plan, there's an added incentive to keep moving: a fitness club reimbursement. This unique benefit, designed to encourage physical fitness among enrollees, offers a $100 reimbursement towards membership at a qualified fitness club. To take advantage of this opportunity, members are required to provide proof of payment alongside a completed Fitness Club Reimbursement form. Qualifying establishments span a wide range from health clubs and gyms equipped with cardio and strength-training machines to gymnastics centers, yoga classes, and martial arts centers, making it easier for every member to find an activity they enjoy. However, it's important to note that not all clubs or activities qualify; exclusions such as beach clubs, country clubs, and sports teams among others are not eligible for reimbursement. Detailed in the reimbursement form are the specifics regarding what constitutes acceptable proof of payment – itemized receipts, membership dues receipts, credit card statements, or statements from the fitness club on official letterhead. Additionally, members are reminded to include their UniCare member ID on all submitted documents and retain copies for their records. The process outlined not only underscores the plan's commitment to fostering a healthier community but also delineates clear steps for members to follow in order to receive their reimbursement, making it a straightforward path to both physical wellness and financial savings.

QuestionAnswer
Form NameUnicare Fitness Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfitness form pdf, fitness form, unicare fitness reimbursement form, unicare state indemnity plan fitness club reimbursement form

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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. 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

Beach clubs

Personal trainers

cardio / strength-training machines,

Country clubs

Sports coaches

as well as other programs

Dance classes/studios

Sports teams/leagues

for improved physical fitness

Exercise machines

Tennis clubs

 

 

Gymnastics centers

Yoga classes

 

Martial arts centers

 

 

 

 

 

 

 

What information do I need to provide?

1.A completed copy of the Fitness Club Reimbursement form (page 2)

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.

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

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Claims are administered by UniCare Life & Health Insurance Company.

UNICARE STATE INDEMNITY PLAN

FITNESS CLUB REIMBURSEMENT (CONTINUED)

For UniCare State Indemnity Plan members

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

Fitness Club Reimbursement

PO Box 9016

Andover, MA 01810-0916

See page 1 for instructions.

UniCare State Indemnity Plan

 

unicarestateplan.com

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