This action might not be possible to undo. Are you sure you want to continue?
PLEASE PRINT ALL INFORMATION CLEARLY SUBSCRIBER INFORMATION (Person in whose name coverage is held) CIGNA ID Number Subscriber’s Last Name Subscriber’s First Name Middle Initial
Address - Number & Street
Member's Last Name First Name Middle Initial Date of Birth
Gender Male 1. Female 2.
Claimant is (Check one) Subscriber 1. Spouse 2.
Child (19 or younger) Handicapped Dependent (19 or older)
5. 6. 7.
Student Stepchild Other
• • •
WHEN TO SUBMIT THIS FORM:
After you have collected paid receipts from your qualified Health Club. Once per plan year, filed within 3 months of the close of the plan year. This benefit allows a reimbursement per plan year (July-June) for Health Club fees. Please note, the benefit maximum is reimbursement per family per plan year.
HEALTH CLUB INFORMATION REQUIRED
(Attach itemized 8.5 x 11 photocopies of paid receipts and a copy of your health club contract or agreement) Name and Address of Health Club Date Membership Began Amount Charged
TOTAL NUMBER OF RECEIPTS ATTACHED:
TOTAL CHARGES: $
All Fitness Benefit payments will be sent to the Employee's address on file. CERTIFICATION AND AUTHORIZATION (This form must be signed and dated below) I authorize the release of any information to CIGNA HealthCare, Inc. about my health club membership. I certify that the information provided in support of this submission is complete and correct and that I have not previously submitted for these services, during this plan year. Employee's/Member's Signature:
Please mail this form (including copies of paid receipts) to:
CIGNA Healthcare Scranton Service Center Attn: Jennifer Petrochko PO Box 3299 Scranton, PA 18505-0299 Note: The program is provided and funded by Staples, Inc. CIGNA HealthCare acts as administrator only.