Unicare Fitness Form – Fill Out and Use This PDF

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 

ec729 (06/18)

Page 1

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	Page 2