HPHC Fitness Reimbursement Form Instructions

Fitness Reimbursement Form Instructions Please read the instructions below, then 昀椀ll out the Fitness Reimbursement Form on page 3. Want your reimbursement faster? Submit your request online at harvardpilgrim.org/昀椀tnessreimbursement. Getting reimbursed is easy Please enclose copies of the following: Copy of your health/昀椀tness membership agreement Mail to: Completed Fitness Reimbursement Form Harvard Pilgrim Health Care P. O. Box 9185 Receipts showing that you paid for at least four months Quincy, MA 02269 in a calendar year for membership or subscription fees (must show your name and the facility or program name). Fees must equal or exceed amounts being claimed. You have questions? We have answers! How do I qualify for a reimbursement? What quali昀椀es for 昀椀tness reimbursement? • You must be eligible for 昀椀tness reimbursement • Full-service health/昀椀tness facilities that have cardiovascular through your Harvard Pilgrim plan. and strength-training equipment qualify, as well as facilities • Fitness facility or other quali昀椀ed 昀椀tness for exercising and improving physical 昀椀tness. membership must be for at least four months • Fitness studios/facilities that offer yoga, Pilates, Zumba, in a current calendar year. aerobic/group classes, indoor cycling/spinning classes, kick- • Current Harvard Pilgrim membership must boxing, CrossFit, strength training, tennis, indoor rock climb- be at least four months in a calendar year ing and personal training (taught by a certi昀椀ed instructor). and must coincide with four months of • Virtual 昀椀tness subscriptions. 昀椀tness membership or subscription. • Not eligible for reimbursement: fees you pay for group When can I submit my Fitness classes or personal training outside of a 昀椀tness facility/ Reimbursement Form? studio, and health club initiation fees or costs that you pay for instructional dance studios, country clubs, social clubs • Starting on May 1 of the current calendar (such as ski, riding or hiking clubs), spas, gymnastics facili- year and when you have met the above- ties, martial arts schools, pool-only facilities, road race fees, stated criteria. sport camps, ski passes, sports teams or leagues, and school sports athletic user fees. • Validation is subject to approval by Harvard Pilgrim. Continued  Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of New England Page 1 of 3 Page 1 of 3 and HPHC Insurance Company.

How much can I claim for 昀椀tness reimbursement?* What happens after I submit the Fitness • When eligible, up to two members on a family plan Reimbursement Form? can be reimbursed for up to $150 each, for a • Reimbursement checks will be mailed and made maximum reimbursement of $300. Any combination payable only to the Subscriber only at the Subscriber’s of subscriber, spouse or dependent is eligible for address of record. No other address will be accepted. reimbursement. For plans with one covered member, If you believe your current address is different from the maximum reimbursement amount is $150. the address we have on 昀椀le, please call the Member • Some members may be eligible for a different Services number on the back of your ID card before reimbursement amount based on their health plan. you submit the form. • Small group or individual plans in MA allow up • Please allow up to 8 weeks for processing. to $150 total for 昀椀tness membership fees and 昀椀tness trackers. • Check with your employer or contact Member Services for eligibility and reimbursement amount. * Fitness reimbursement may be considered taxable income. For tax information, consult your employer or tax advisor. Page 2 of 3

Fitness Reimbursement Form To be 昀椀lled out by Harvard Pilgrim Health Care • After you have been a member in quali昀椀ed 昀椀tness program and SUBSCRIBER only. Please use blue or black ink Harvard Pilgrim Health Care for at least four months in a calendar year. and print all information clearly. • Once per calendar year, submitted by March 31 of the following year, with all necessary receipts or proof of payment. Some small group and When to submit this form individual plans have until December 31 of the following calendar year • When you are eligible for 昀椀tness reimbursement through your to submit for reimbursement. employer or individual plan. • After all sections have been completely 昀椀lled out and signed by the subscriber. Section A – Subscriber Information (person who holds coverage) Harvard Pilgrim ID Number Subscriber’s Last Name First Name Middle Initial Date of Birth (mm/dd/yyyy) Address City State ZIP Code Daytime Phone (area code) xxx-xxxx Company Name (Employer) Subscriber’s Email Section B – Subscriber and/or Member Information for Reimbursement Harvard Pilgrim ID Number Last Name First Name Date of Birth (mm/dd/yyyy) Harvard Pilgrim ID Number Last Name First Name Date of Birth (mm/dd/yyyy) Section C – Fitness Program Information (List all health and facility memberships that you and/or your dependent(s) are submitting for reimbursement spanning the qualifying four months.) Calendar Year Phone Number from: mm/dd/yyyy Facility or (Area Code) $ Amount TION to: mm/dd/yyyy Program Name City, State xxx-xxxx being claimed A ACH from: ____/____/____ TT to: ____/____/______ A from: ____/____/____ DOCUMENTto: ____/____/______ Section D – Fitness Tracking Device Information (List the brand – i.e., Apple Watch, Fitbit, Garmin, Nike, Samsung Gear, etc.) (NOT ALL MEMBERS ARE ELIGIBLE FOR THIS REIMBURSEMENT; see instructions on page 2) Purchase Date Tracking Device Brand $ Amount being claimed ACH TT A RECEIPT Total number of documents _____Total dollar amount being claimed $_______________ Section E – Subscriber Certi昀椀cation I certify the information on the form and all supporting documents are complete, accurate and unaltered. I will attempt, in good faith, to regularly use my 昀椀tness services for which I am being reimbursed. Subscriber’s Signature Date * Fitness reimbursement may be considered taxable income. For tax information, consult your employer or tax advisor. Page 3 of 3 CW777174103-11/21