Medicare Fitness Reimbursement Claim Form

Medicare Fitness Reimbursement Claim Form
Submit your claim for eligible fitness membership reimbursement under your Medicare plan.
Claimant Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Medicare Plan Name
Member ID (Do not enter your Social Security or National ID number)
Fitness Facility or Program Name
Type of Membership or Program
Claim Period (Start Date)
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Claim Period (End Date)
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Amount Requested for Reimbursement (USD)
Upload Receipt or Proof of Payment
Cancelof
Signature (Required to process your claim)
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