Blue cross blue shield fitness reimbursement 2021-2025

1. Click ‘Get Form’ to open the blue cross blue shield fitness reimbursement 2021 form in the editor.
2. Begin by filling in the Subscriber Information section. Enter your Identification Number, Last Name, First Name, Address, City, State, Zip Code, and Employer’s Name clearly.
3. Next, complete the Member Information section. Provide the Member’s Last Name, First Name, and Gender. Indicate the relationship of the claimant to the subscriber and fill in their Date of Birth.
4. In the Health Club Information Required section, attach photocopies of dated health club receipts and your health club agreement. Fill in the name and address of your health club along with the Benefit Year.
5. Finally, sign and date the Certification and Authorization section to confirm that all information is accurate. Ensure you have included all necessary attachments before submitting.

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