Fitness, Health & Wellness Form

Fitness, Health & Wellness Form
**Please refer to your Summary Plan Description (SPD) for specific details regarding your Fitness/Health or Wellness Plan. The information and examples provided below are not all-inclusive and do not cover all plan requirements for reimbursement. Some plans may require completion of a certain number of classes or a minimum duration of paid membership before reimbursement is eligible.**

**This claim form must be submitted with a copy of an itemized bill on the provider’s letterhead to qualify for reimbursement. All sections below must be completed.**
Section 1: Employee Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member ID Number
Employer Name
Group Number (from your ID card)
Section 2: Claimant Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Relation

Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 3: Benefit Type (Refer to the Summary Plan Description for Coverage Details)
To be eligible for reimbursement, the covered person must submit a claim along with a paid receipt or itemized statement from the rendering provider no later than March 31 of the year following the year in which the benefit is claimed.
Members Statement
I certify that the information provided above is complete and accurate, and that I am claiming benefits only for charges incurred by the patient identified above. I hereby authorize any hospital, physician, or other healthcare provider involved in my care and treatment to release to BBA any information they deem necessary for the adjudication of this claim.
Itemized Bill

Cancelof
Member Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Fitness, Health & Wellness Form

Section 1: Employee Information

Section 2: Claimant Information

Section 3: Benefit Type (Refer to the Summary Plan Description for Coverage Details)

Members Statement