Use these forms if you are submitting for the 2018/2019 plan year.
Your physical occurred between July 1, 2018 and June 30, 2019
Your wellness activity occurred and was paid for between July 1, 2018 and June 30, 2019
- Fitness Activity Fee Reimbursement - membership fees (gym or aquatic center) and classes
A membership contract and/or fee schedule MUST be submitted with your proof of payment and claim form
- Annual Physical Exam Rewards
Language indicating the patient was seen for a preventive visit must be included on medical facility letterhead or a physician's script pad
- Plan year is July 1, 2018 - June 30, 2019
Deadline for submission is July 15, 2019. Late submissions will not be accepted
- Please read all guidelines
Wellness Activity Fee Reimbursement:
Your activity reimbursement will not be processed without a contract or fee schedule from the facility. This is required for all claims.
2018-2019 Wellness Activity Form
Physical Exam Reward:
2018-2019 Annual Physical Reward