Weight Management Program Reimbursement Form To be 昀椀lled out by Harvard Pilgrim Health Care SUBSCRIBER only. Please use blue or black ink and print all information clearly. When to submit this form • After you enroll in a Harvard Pilgrim plan that includes the Weight Management Program Reimbursement bene昀椀t • After you are a member of an approved weight management program • Once per calendar year, with all necessary receipts and documentation • Once all sections on the form have been completed and signed by the subscriber Section A – Subscriber Information (person who holds coverage) Harvard Pilgrim ID Number Subscriber’s Last Name First Name Middle Initial Date of Birth (mm/dd/yyyy) Address City State ZIP Code Daytime Phone (area code) xxx-xxxx Company Name (Employer) Subscriber’s Email Section B – Subscriber and/or Member Information for Reimbursement Harvard Pilgrim ID Number Last Name First Name Date of Birth (mm/dd/yyyy) Harvard Pilgrim ID Number Last Name First Name Date of Birth (mm/dd/yyyy) Harvard Pilgrim ID Number Last Name First Name Date of Birth (mm/dd/yyyy) Section C – Weight Management Program Information (List all programs that you are submitting for on behalf of you and/or your dependents, including the qualifying months.) Calendar Year from: mm/dd/yyyy Phone Number $ Amount TION to: mm/dd/yyyy Type of Program City, State (area code) xxx-xxxx being claimed A from: ____/____/____ to: ____/____/______ from: ____/____/____ to: ____/____/______ ACH DOCUMENT TT from: ____/____/____ A to: ____/____/______ Total number of documents _____ Total dollar amount being claimed $_______________ Section D – Subscriber Certi昀椀cation I certify that the information on the form and all supporting documents are complete, accurate and unaltered. I af昀椀rm that I will attempt, in good faith, to regularly attend my weight management program and utilize membership for which I am being reimbursed. Subscriber’s Signature Date Page 2 of 2 cc6543 3_21