Transcription of Weight-Loss Reimbursement Request
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Weight-Loss Reimbursement Request
To verify this Reimbursement is offered within your plan, or for more information, please log on to MyBlue at or call the Member Service number on your ID card. All Weight-Loss Reimbursement requests must be submitted by March 31 of the following Information (Policyholder)Identification Number on Subscriber ID Card (including first 3 characters)Subscriber s Last NameFirst NameMiddle InitialAddress Number and StreetCityStateZip CodeEmployer s NameClaim InformationMember s Last NameFirst NameMiddle InitialDate of Birth: MM/DD/YYGender (color in the entire box): Male FemaleClaim is for (choose one and color in the entire box): Subscriber (policyholder) Ex-Spouse Other (specify)_____ Spouse (of policyholder) Dependent (up to age 26) Name, Address, and Phone Number of Qualified Weight-Loss ProgramTotal dollars requested: $ _____Monthly program participation fee.
or call the Member Service number on your ID card. All weight-loss reimbursement requests must be submitted by March 31 of the following year.
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