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The Oxford Gym Reimbursement form is an essential tool for members seeking to make their fitness journey more financially rewarding. Through this program, participants can receive reimbursement for their gym fees or fitness class expenses by documenting their visits and engagements over a six-month period. The form requires members to track a minimum of 50 visits to fitness facilities or classes, ensuring they stay committed to their health goals. Additionally, it provides clear instructions on documenting these visits, whether through manual entry or by attaching printed records from the gym. The reimbursement process encourages members to maintain an active lifestyle while rewarding them financially for their effort. To ensure smooth processing, the form outlines critical deadlines, including the need for timely submissions within 180 days of the program's end date. Furthermore, members must include proof of payment and verify their usage of cardio-promoting sessions, ensuring transparency and accountability. Overall, the Oxford Gym Reimbursement form not only incentivizes physical fitness but also creates a straightforward pathway for members to reclaim some of their fitness-related expenses.

Oxford Gym Reimbursement Example

Oxford® Sweat Equity Program

Reimbursement Form

Please Print

Member name: _____________________________________ Street address: ___________________________________________

Date of birth: ___________________City, State, ZIP code: ___________________________________________________________

Oxford member ID number: _____________________________________

Six-month period program start date: ______________________ Six-month period program end date: _______________________

Completing and Submitting This Form

1.Record the 50 fitness facility visits and/or classes that you went to in a six-month period on the chart shown below. (Record only one session per day.)

The first date you put on the chart is the beginning of your six-month program period.

The last date you put on the chart should be on or before the last date of the six-month period that you are asking for reimbursement. Do not include any facility visits or classes after this date.

Note: Instead of filling in the dates of your 50 workouts, you can attach to this form one of the following documents:

A computer printout of your visits to the fitness facility and/or classes completed, including dates and the name of the place.

Receipts that show the dates of your fitness facility visits and/or classes, with the name of the place.

Your documentation must include signatures from a facility representative or class administrator to prove the use.

2.Attach proof of payment (e.g., receipt, payroll deduction, automatic bank withdrawal statement) for the fitness facility fee, as well as any money you paid for fitness classes, during the six-month period.1

3.Enclose a copy of the brochure or flier that describes the cardio equipment at the facility you used or the cardio benefits of the class you took.

4.Mail documentation to:

Oxford Sweat Equity Reimbursement Program P.O. Box 29130

Hot Springs, AR 71903

Note: These documents must be mailed to us (postmarked) no later than 180 days from the last date of the six-month period that you are asking to be reimbursed. Requests postmarked after this date won’t

be reimbursed.

5.Questions? Please call us at the toll-free phone number (“For Members”) on the back of your health plan ID card.

Fitness Facility Visits and Classes (Record only one session per day.)

Date

Session

Date

Session

Date

Session

(mm/dd/yyyy)

Type*

(mm/dd/yyyy)

Type*

(mm/dd/yyyy)

Type*

 

 

 

 

 

 

1. (six-month start date)

F/C

18.

F/C

35.

F/C

 

 

 

 

 

 

2.

F/C

19.

F/C

36.

F/C

 

 

 

 

 

 

3.

F/C

20.

F/C

37.

F/C

 

 

 

 

 

 

4.

F/C

21.

F/C

38.

F/C

 

 

 

 

 

 

5.

F/C

22.

F/C

39.

F/C

 

 

 

 

 

 

6.

F/C

23.

F/C

40.

F/C

 

 

 

 

 

 

7.

F/C

24.

F/C

41.

F/C

 

 

 

 

 

 

8.

F/C

25.

F/C

42.

F/C

 

 

 

 

 

 

9.

F/C

26.

F/C

43.

F/C

 

 

 

 

 

 

10.

F/C

27.

F/C

44.

F/C

 

 

 

 

 

 

11.

F/C

28.

F/C

45.

F/C

 

 

 

 

 

 

12.

F/C

29.

F/C

46.

F/C

 

 

 

 

 

 

13.

F/C

30.

F/C

47.

F/C

 

 

 

 

 

 

14.

F/C

31.

F/C

48.

F/C

 

 

 

 

 

 

15.

F/C

32.

F/C

49.

F/C

 

 

 

 

 

 

16.

F/C

33.

F/C

50. (six-month end date)

F/C

 

 

 

 

 

 

17.

F/C

34.

F/C

*Indicate “F” for Facility/Gym; “C” for Class.

 

 

 

 

 

 

1On your proof of payment, please be sure to cross out any personal account ID information that’s not needed so it isn’t readable.

Fitness Facility Information

Facility name: ________________________________________

Facility name (if a second facility was used): ___________________

Facility type: __________________________________________

Facility type: __________________________________________

Address: ____________________________________________

Address: _____________________________________________

City, State, ZIP code: ___________________________________

City, State, ZIP code: ___________________________________

Telephone number: ____________________________________

Telephone number: ____________________________________

Fitness Class/Session Information

Names of class(es)/session(s): __________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Fitness Center/Instructor Information

Facility employee/Class instructor name: _________________________________________________

Signature: __________________________________________________________________________ Date: ___________________

Instructor or other facility employee’s signature above shows that the instructor/facility encourages cardio wellness for members.

Member Verification

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. In New York, any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

My signature below confirms that all of the information I have provided on this form and attached is full, complete and true to the best of my knowledge.False statements will result in the denial of reimbursement.

Signature of Sweat Equity member: _____________________________________________________ Date: ___________________

Exclusions and Limitations

Participation in this program is completely voluntary and at the discretion of the member and his or her physician.

For this program, the use of “you” and “member” in communications refers to the Oxford plan subscriber or the subscriber’s covered spouse or domestic partner; no other covered dependents are eligible. The program is not available to all Oxford plan subscribers and their spouses or partners, including those affiliated with any Connecticut plan and some New York and New Jersey plans.

Refer to your Certificate of Coverage, Summary Plan Description or other governing member document to determine eligibility for this reimbursement, confirm your plan’s benefit and for application deadlines.

To be eligible for reimbursement under the program, the qualifying facility or classes that you choose must be available to the general public and promote cardiovascular wellness, as determined by us, and have staff supervision.

You must be an active employee at the time of your application for reimbursement. We will reimburse only those qualified visits or sessions that were completed while you were a member of the Oxford plan. We will not reimburse visits that occurred before your coverage became effective or after your coverage terminates. Partial reimbursements will not be given for fewer than 50 workouts in a six-month period.

You must hold an active fitness facility or class membership for the facility/class named in the request at the time of your application for reimbursement.

Memberships in tennis clubs, country clubs, social clubs, sports teams, weight loss clinics or spas or any other similar organizations, leagues or facilities will not be reimbursed. We will not reimburse you for the purchase of lessons, equipment, clothing, vitamins or other items or services that may be offered by the facility. Reimbursement is limited to actual workout visits. Physical and rehabilitative therapies do not apply.

Lifetime memberships are not eligible for reimbursement.

If you paid for a full-year’s facility membership or class enrollment in advance, at the end of the first six-month period for which you are applying for reimbursement, submit the receipt along with the required documentation noted above for reimbursement against half of the annual fee that you paid. Repeat this process at the end of your second six-month period for which you made a full-year’s payment providing you have met the requirements for another, consecutive reimbursement.

Complete one form per member, for each six-month period for which you are applying for reimbursement.

If any information is missing from this form, incorrect or cannot be substantiated, the application for reimbursement will be delayed or denied.

Any information we collect in conjunction with this program is kept confidential according to HIPAA requirements and is separate from and has no effect on a member’s medical benefits or premium.

You should consult with an appropriate tax professional to determine if you have any tax obligations from receiving reimbursement under this program. Use one form per subscriber/subscriber’s covered spouse/domestic partner.

Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. and Oxford Health Plans (NJ), Inc.

Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

MS-16-347 9/16 ©2016 Oxford Health Plans LLC. All rights reserved. 16-2207 (NY/NJ/CT)

Form Characteristics

Fact Name Description
Reimbursement Eligibility Members must have at least 50 visits to fitness facilities or classes within a six-month period to qualify. Partial reimbursements are not available.
Documentation Required Members need to submit proof of visits, proof of payment, and promotional material from the fitness facility or class.
Submission Deadline Claims must be postmarked within 180 days from the last date in the six-month period for which reimbursement is requested.
Governing Laws This program is subject to New York insurance laws, which state that false claims may result in criminal and civil penalties.

Guidelines on Utilizing Oxford Gym Reimbursement

Completing the Oxford Gym Reimbursement form is essential for those looking to reclaim their fitness expenses. Each step must be followed carefully to ensure successful processing of your claim. Keep in mind that certain documentation is required, and deadlines are strict. Here’s how to navigate the form efficiently:

  1. Fill out your personal information: Write your name, street address, date of birth, city, state, ZIP code, and Oxford member ID number at the top of the form.
  2. Record your fitness visits: In the chart provided, list the dates of your sessions. Make sure to note only one visit per day. Your first date should mark the beginning of your six-month program. The last date entered must fall within the ending period you’re requesting reimbursement for. If preferred, you can attach a computer printout or receipts proving your attendance instead.
  3. Attach proof of payment: Include any documents, such as receipts or bank statements, that confirm payment for your fitness facility and classes during the six-month period.
  4. Include facility information: Fill in details about the fitness center you used, including the facility's name, type, address, city, state, ZIP code, and contact number. If you visited a second facility, repeat this step for those details.
  5. Document class information: If applicable, list the names of the classes or sessions you attended in the designated area on the form.
  6. Get verification: Have the facility employee or class instructor sign the form to validate your participation in the program. Make sure the date is noted as well.
  7. Sign and date the form: Confirm the accuracy of all the information by signing and dating the form at the bottom. Ensure that you understand the implications of providing false information.
  8. Mail your documentation: Send all the completed documents to the address provided: Oxford Sweat Equity Reimbursement Program, P.O. Box 29130, Hot Springs, AR 71903. Ensure it is postmarked no later than 180 days after your six-month period ends.

Be proactive about submitting your form and supporting documents to avoid any delays or rejections. Remember, each detail matters when it comes to making your fitness investments work for you.

What You Should Know About This Form

What is the Oxford Gym Reimbursement Form?

The Oxford Gym Reimbursement Form is a document used by members of the Oxford® Sweat Equity Program to request reimbursement for gym expenses. Members must provide proof of fitness facility visits, payment, and related documentation to receive reimbursement.

Who is eligible to submit this form?

Eligible individuals include Oxford plan subscribers and their covered spouse or domestic partner. Other covered dependents are not eligible. Participation is voluntary and only available to active employees at the time of application.

What information do I need to fill out the form?

You must provide your name, address, date of birth, Oxford member ID number, and the start and end dates of your six-month program period. You will also need to record the dates of your facility visits and include payment proof and documentation of your cardio activities.

How do I document my fitness facility visits?

Record your visits on the chart provided in the form. You can also attach a computer printout or receipts showing the dates and facility names. Make sure to get a signature from a facility representative or class administrator to validate your visits.

What types of payments are acceptable for reimbursement?

Acceptable proof of payment includes receipts, payroll deductions, or automatic withdrawal statements. Just be sure to redact any unnecessary personal account details on these documents.

What documents must I submit with the form?

In addition to the completed reimbursement form, you need to attach proof of payment, documentation of your visits or classes, and a brochure or flyer that describes the cardio equipment or class benefits.

What is the submission deadline for the form?

Your request must be postmarked within 180 days of the last date of the six-month period for which you are applying. Late submissions will not be reimbursed.

What happens if my form is incomplete or incorrect?

If the form is missing information or if details cannot be substantiated, processing may be delayed or your reimbursement request may be denied. Ensure all information is accurate and complete.

Are there any exclusions or limitations for this program?

Yes, memberships in certain clubs, spas, or weight loss clinics are not eligible for reimbursement. Only visits that promote cardiovascular wellness and that are taken while you are an active Oxford member qualify. Lifetime memberships are also not eligible.

How do I get assistance if I have questions about the form?

If you have questions, call the toll-free number listed on the back of your health plan ID card. There is support available to help you navigate the form and reimbursement process.

Common mistakes

Completing the Oxford Gym Reimbursement form requires attention to detail. One common mistake is failing to record all 50 fitness facility visits or classes as required. Individuals may inadvertently skip entries or miscount their total visits, leading to incomplete submissions. It is crucial to verify that each entry is accurately documented, as missing information can result in a denial of reimbursement.

Another frequent error involves not adhering to the date requirements specified for the six-month program period. Some may mistakenly include workout sessions that fall outside of the designated start and end dates. This mistake can jeopardize an otherwise eligible claim, as only workouts conducted within the defined timeframe qualify for reimbursement.

Many individuals also neglect to include the necessary proof of payment. This proof can consist of receipts, payroll deductions, or automatic bank withdrawal statements. Submitting the form without this documentation is a significant oversight that can delay or deny reimbursement requests.

An additional misstep occurs when members do not attach the required brochure or flier describing the cardio equipment or class benefits. Omitting this document could lead the reviewer to question the validity of the workouts claimed, resulting in complications during the claims process.

Some participants mistakenly assume that improper or insufficient documentation will be accepted. Lack of signatures from a facility representative or instructor can invalidate the claims submitted, as verification of facility use is a requirement. Therefore, ensuring that all necessary signatures are obtained is essential.

Failing to mail the completed application within the stipulated time frame is another notable pitfall. Submissions must be postmarked no later than 180 days after the end of the six-month period. Late submissions risk automatic denial, regardless of eligibility.

Inaccurate fitness facility information is another mistake that can hinder claim processing. Providing the wrong facility name or type can lead to confusion during the review process, potentially resulting in a claim being considered invalid.

Some individuals overlook the instruction to submit only one form per six-month period for each member. Multiple applications submitted for the same period can create administrative challenges and may lead to denial or requests for clarification, further complicating the reimbursement process.

Lastly, a significant misunderstanding lies in the nature of eligible facilities and classes. Memberships with tennis clubs, social clubs, or similar organizations do not qualify for reimbursement. Therefore, ensuring that the chosen clinics adhere to the program's eligibility is vital for successful claims.

Documents used along the form

The Oxford Gym Reimbursement Form is just one of the several documents you may need when submitting your request for reimbursement. Each of these documents plays a crucial role in ensuring that your reimbursement request is processed efficiently. Below is a list of commonly required forms and documents that accompany the Oxford Gym Reimbursement Form.

  • Fitness Facility Visit Log: This log records each visit to the gym or class sessions during the six-month period. It's often used to verify attendance and ensure that the number of visits aligns with what is stated on the reimbursement form.
  • Payment Receipts: Receipts showing proof of payment for gym memberships or fitness classes are essential. These documents help substantiate the amounts paid and ensure that they fall within the applicable dates for reimbursement.
  • Facility Brochure or Flyer: Including a brochure detailing the cardio equipment or fitness classes offered by the facility enhances the reimbursement request. This document provides proof that the facility promotes cardiovascular wellness, a key component for eligibility.
  • Proof of Enrollment: Proof of current membership or class enrollment is often requested. This can be a copy of a membership card or an enrollment confirmation email, verifying your active status at the time of your reimbursement request.
  • Exercise Class Attendance Records: If you attended specific classes, attendance records from the facility may be necessary. These records show class dates and instructor information, further corroborating your fitness engagement.
  • Facility Representative Signatures: Signatures from instructors or facility staff on related documents confirm that you attended classes. These endorsements act as verification of your participation in the fitness programs.
  • Active Employment Verification: Some reimbursement programs require proof that you are actively employed to ensure eligibility. This could come as a recent pay stub or an employment verification letter.
  • Medical Clearance Documentation: In some cases, especially if recommended by a healthcare provider, you may need to include a note from a physician that supports your participation in the fitness program.

By gathering these documents and ensuring they are accurate and complete, the submission process can be smooth, enabling quicker reimbursement decisions. Always check for any additional requirements specific to your plan, as these can vary. If you have any questions, don’t hesitate to reach out for guidance.

Similar forms

  • Health Reimbursement Account (HRA) Claim Form: Similar to the Oxford Gym Reimbursement form, an HRA claim form allows members to request reimbursement for eligible medical expenses. Both forms require proof of service or attendance and include unique member identification details.
  • Flexible Spending Account (FSA) Reimbursement Form: FSA reimbursement forms enable employees to claim back out-of-pocket medical costs. Like the Oxford Gym form, these require documentation of expense and specific information about the individual seeking reimbursement.
  • Wellness Program Reimbursement Request: Much like the gym reimbursement form, wellness program Request forms facilitate reimbursement for expenses related to health and fitness initiatives. Both forms require a commitment to certain health activities supported by documentation.
  • Dependent Care Assistance Program (DCAP) Claim Form: While targeted at care-related expenses for dependents, both forms necessitate detailed record-keeping and proof of payment, confirming eligibility under specific guidelines.
  • Tuition Reimbursement Request Form: Similar in structure, both forms ask for individual details, proof of expense, and require submission within a specific timeline to facilitate reimbursement. Both support member engagement in personal growth.
  • Medical Expense Reimbursement Request Form: Akin to the Oxford Gym Reimbursement form, this document aids in claiming eligible medical costs. Evidence of payments and services is essential for both forms, ensuring accountability.
  • Fitness Class Attendance Verification Form: This document shares similarities with the gym reimbursement form, as it confirms attendance at fitness-related classes. Documentation and validation of participation are imperative in both formats.
  • Chiropractic Treatment Reimbursement Form: Both forms facilitate claims for specific health-oriented expenses. They require detailed disclosures about visits and payments, and both must be submitted promptly to receive reimbursement.

Dos and Don'ts

When filling out the Oxford Gym Reimbursement form, it's important to follow specific guidelines to ensure a smooth application process. Below are some essential do's and don'ts to keep in mind.

  • Do accurately record all 50 fitness facility visits or classes on the chart provided.
  • Do attach proof of payment for the fitness facility fee and any classes you attended during the six-month period.
  • Do include documentation that includes signatures from a facility representative or class administrator.
  • Do mail all completed documentation to the address listed on the form within the required timeframe.
  • Do keep a copy of all documents for your records before sending them in.
  • Don't submit any facility visits or classes that occur after the end date of the six-month period.
  • Don't provide any false or misleading information on your form.
  • Don't forget to cross out unnecessary personal account ID information on proof of payment.
  • Don't rely on verbal confirmations; always document everything in writing.
  • Don't submit incomplete or missing information, as it may delay or deny your application.

Misconceptions

Misconceptions about the Oxford Gym Reimbursement form can lead to confusion and missed opportunities. Here are ten common misconceptions along with clarifications:

  1. Anyone can get reimbursed. Only active employees of Oxford and their covered spouses or domestic partners can apply. Other dependents do not qualify.
  2. All fitness activities qualify. Only visits to facilities that promote cardiovascular wellness and are open to the public are eligible. This excludes clubs or teams.
  3. You can submit visits after the six-month period. No, submissions must be postmarked within 180 days of the end date of the six-month period you are claiming.
  4. Partial reimbursements are available. You cannot receive partial reimbursement. A minimum of 50 workouts within the specified time frame is required.
  5. Documentation is optional. Accurate documentation, including proof of visits and payment, is mandatory for processing your reimbursement request.
  6. Lifetime memberships are eligible. No, lifetime memberships do not qualify for reimbursement under this program.
  7. Previous or future visits can be included. Visits or classes must occur after your coverage begins and before it ends. Only the specified six-month period counts.
  8. Any receipts are accepted. Receipts must specifically show your fitness facility visits or class attendance, including dates and signatures from facility staff.
  9. You can submit one form for multiple members. Each member must complete a separate form for reimbursement; do not combine requests on one form.
  10. Tax obligations do not matter. It's essential to consult with a tax professional about any implications associated with receiving reimbursement under this program.

Understanding these points will help avoid unnecessary delays and ensure proper reimbursement under the Oxford Gym Reimbursement form.

Key takeaways

Here are key takeaways regarding the Oxford Gym Reimbursement form:

  • Provide Accurate Information: Ensure that all personal details are filled out completely and accurately, including your member ID and date of birth.
  • Track Fitness Visits: You must record a maximum of 50 visits to a fitness facility or classes during the specified six-month period.
  • Document Dates: Only include workouts that occurred on or before the end date of the six-month period you are seeking reimbursement for.
  • Proof of Participation: Attach a computer printout or receipts confirming the dates and names of the facilities or classes you attended, including required signatures.
  • Proof of Payment: Include evidence of payment, such as receipts or bank statements, for your facility fees and class payments during the six-month timeframe.
  • Additional Documentation: Enclose a brochure or flyer that showcases the cardio equipment or benefits associated with the class you participated in.
  • Submission Deadline: Mail your completed documentation within 180 days of the end of the six-month period to ensure reimbursement eligibility.
  • Contact for Questions: For any inquiries, use the toll-free number provided on your health plan ID card.
  • Individual Applications: Each member must submit a separate reimbursement form for each six-month period they wish to claim.
  • Validity of Claims: Ensure your claims contain truthful and accurate information to avoid delays or denials in reimbursement.