Templateroller template2276897New Hampshire Fitness Reimbursement Form for Anthem Members 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal information in the unshaded areas. Include your last name, first name, member identification number, date of birth, and sex.
3. Next, provide your subscriber information including the last name, first name, street address, city, state, ZIP code, and phone number. If this is a new address, check the appropriate box.
4. In the section for fitness center details, enter the fitness center's name and address. Ensure you include the workout period dates and amount paid by you.
5. Both you and a fitness center employee must sign the form to authorize the release of necessary information to Anthem. Make sure to date the form upon completion.
6. Finally, attach original receipts to the back of this form and send it to the Claims Department at Anthem Blue Cross and Blue Shield.

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