Staples - Wellness Claim Form doc 2026

1. Click ‘Get Form’ to open the Staples - Wellness Claim Form in our editor.
2. Begin by filling out the MEMBER INFORMATION section. Clearly print your UnitedHealthcare ID Number, Subscriber’s Last Name, First Name, Middle Initial, Address, City, State, and Zip Code.
3. Next, gather your receipts for qualified expenses such as Health Club memberships or Fitness Equipment purchases. Ensure you have itemized photocopies of these receipts ready to attach.
4. In the INFORMATION REQUIRED section, specify the name of the Health Club or Weight Loss Program and provide the date when your membership began or when you purchased fitness equipment.
5. Enter the total amount you are submitting for reimbursement in the TOTAL CHARGES field.
6. Finally, complete the CERTIFICATION AND AUTHORIZATION section by signing and dating the form. Make sure all information is accurate before submission.

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