Strength Training Fitness Equiptment S3 19 Pw 002396
User Manual: Strength-Training Fitness Equiptment S3-19
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It pays to join a fitness center.
What you get:
You or your family can get up to $200 per subscriber
contract, per calendar year for membership dues at a
fitness center. You just need to exercise regularly. Because
plans vary, you will want to make sure you’re eligible for
this fitness reimbursement program. Just call the
Customer Service number on the back of your ID card.
How it works:
You’ll choose an established fitness center that offers the
type of classes, programs, and fitness equipment that’s
right for you.
Let’s say you join a YMCA, and you want to use the
cardiovascular equipment, such as a treadmill or rowing
machine. To qualify for your reimbursement, you must meet
the minimum exercise requirements: Exercise at your fitness
center 48 times within the calendar year. Each time you
exercise, record it on your Fitness Reimbursement Program
Log Card and ask a fitness center staff person to initial it, or
get a copy of your fitness center’s computer printout.
We set up these minimum levels of activity to make sure
you’re getting benefits from your efforts. Of course, to get
the most from your workouts, you should exercise at least
three times a week, year-round.
Reimbursement steps:
1. Pay your fitness center dues and keep the receipt(s).
Receipts must be original and include the name of
the fitness center, description of the membership
purchased, date of payment, amount paid and the
name of the person using the membership.
If your fitness center dues are electronically debited
from your bank account, ask for a receipt or submit
copies of your bank statements with the specific
withdrawals circled.
2. Start your exercise program. Use the Fitness
Reimbursement Program Log Card to record each
time you exercise and ask a fitness center staff
member to initial it. Or, use your fitness center’s
computer print out.
3. Complete the Fitness Reimbursement Form.
Instructions are on the back of the form.
4. Mail your completed Fitness Reimbursement Form,
Fitness Reimbursement Program Log Card and
original receipt(s) to:
Claims Department
Anthem Blue Cross and Blue Shield
P.O. Box 533
North Haven, CT 06473-0533
SpecialOffers@Anthem
Fitness Reimbursement Program
35648NHMENABS 2/13
©2010 copyright of Anthem Insurance Companies, Inc.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield
names and symbols are registered marks of the Blue Cross and Blue Shield Association. All of the offerings in the SpecialOffers@Anthem program are continually being evaluated and expanded so the offerings may change. Any additions or changes will be communicated on
our website, anthem.com. These arrangements have been made to add value for our members. Value-added services and products are not covered by your health plan benefit. Available discount percentages may change or be discontinued from time to time without notice.
Discount is applicable to the items referenced.
Exercise requirements:
Regular exercise is an essential part of good health. But to
reap the benefits, you have to do it! To be eligible for
reimbursement, you must meet minimum levels of exercise
activity in a calendar year:
Exercise at least 48 times within the calendar year.
Complete a Fitness Reimbursement Program Log Card or
use your fitness center’s computer printout. If using the
Log Card, Have a fitness center staff member initial it
each time you work out.
Fitness reimbursement rules:
The reimbursement is on a calendar-year basis
(January 1 – December 31 of a given year). Log cards,
fitness center printouts and receipts must reflect
activity within a calendar year.
Workouts must be recorded on the Fitness
Reimbursement Program Log Card or on the fitness
center’s computer printout.
We will not accept photocopies of receipts or log cards.
Reimbursement is limited to a maximum of $200 per
subscriber contract, per calendar year based on the
amount shown on the receipt(s) submitted.
No credit will be issued for unused portions of the
calendar-year fitness reimbursement.
We must receive your reimbursement request within
one year of completing your Fitness Reimbursement
Program Log Card or your computer printout from
your fitness center.
The following are not eligible for reimbursement:
Guest fees, equipment fees, court time fees,
waived membership fees, tournament fees, social
memberships, country club dues, lesson charges
and all other miscellaneous fees.
You are not eligible for this program if your health plan
membership has lapsed for any reason. Your health plan
membership must be in effect while you are taking part
in this program.
This Fitness Reimbursement Program must be available
under your plan. To make sure you’re eligible, call the
Customer Service number on the back of your ID card.
Fitness
Reimbursement Form
— Important —
Please read and follow the instructions located on the front and back of this form. You are required to complete all unshaded
areas of the form by printing clearly with a non-erasable ink pen. This form will be returned if: 1) The form is not completed
with the required information and 2) an original receipt and completed log card or fitness center printout are not attached
to the back of this form. Anthem Blue Cross and Blue Shield will send reimbursement to the subscriber when approved.
Please expect 6-8 weeks to process once Anthem Blue Cross and Blue Shield receives this request for reimbursement.
1. Member’s name: (last) (first) (m.i.)
_____________________________________________________________________ 2. Member’s Identification Number as shown on your
ID card:
___ ___ ___ ________________________
(Anthem Blue Cross and Blue Shield Members, include
your 3-letter prefix)
3. Member’s date of birth:
Mo. _________ Day ________ Yr. _________
4. Member’s sex: Male
Female
5. Group (Employer) name: ______________________________________________________
Division Number: ___________________________________________________________
6. Subscriber’s name (if other than member): (last) (first) (m.i.)
_____________________________________________________________________
7. Subscriber’s address:
Street _______________________________________________________________________________________________________
City __________________________________________________________________ State _______________ Zip _______________
Check box if new address Telephone _______________________________________
8. Subscriber’s address:
Street _______________________________________________________________________________________________________
City __________________________________________________________________ State _______________ Zip _______________
Check box if new address Telephone _______________________________________
DO NOT WRITE IN SHADED AREAS
9. Provider number: 82-9999999-NH-01
10. Workout Period: (MO./Day/Yr.) 11. Place of service:
0L
12. Diagnosis Code:
799.89
13. Amount paid
by member:
$ .
14. Date form completed:
From To
15. Procedure Code:
S9970
16. W authorize the release to Anthem Blue Cross and Blue Shield of any information necessary to process this request for fitness reimbursement.
We agree to the information written above, and verify that the member met the requirements of the program.
X ________________________________________________________________________________________
(Member signature)
X ________________________________________________________________________________________
(Signature of fitness center employee)
The person signing this form is advised that the willful entry of false or fraudulent information renders you liable to be withdrawn from this quit smoking program.
–Thank you –
– turn over for instructions –
35932NYMENABS 2/13
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc.
Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Reimbursement Instructions
The Fitness Reimbursement Form is to be completed by the member attending the fitness center and by a representative
of the fitness center. Attach the completed log card or fitness center printout and original receipts or withdrawal
statements to the back of this form.
To complete this form:
1. Fill in all unshaded sections.
2. Sign the form. Also have a fitness center employee sign the bottom of the form.
3. Date the form when completed. Keep a copy for your records. (We will not return the form.)
4. Send the completed Fitness Reimbursement Form, completed log card or fitness center printout
and original receipt to:
Claims Department
Anthem Blue Cross and Blue Shield
P.O. Box 533
North Haven, CT 06473-0533
5. If you have any questions about this program, call the Customer Service number on the back of your ID card.
Member reimbursement will be denied if:
1. The member was not a current or eligible Anthem Blue Cross and Blue Shield member while taking part in
the program.
2. The member did not complete the requirements of the program.
This form will be returned if:
1. The form is not completed with the required information and;
2. An original receipt or copies of withdrawal statements and log card or fitness center printout are not attached to the
back of this form.
