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2024 Fitness reimbursement

form

ECHS Category: SP07

Aetna® Medicare fitness reimbursement pays members back for certain supplies and activities that

may improve fitness and health

outcomes.

Before you proceed, respond to the following questions to determine reimbursement eligibility. If any of

the questions below are answered “No,” the item is not eligible for reimbursement.

1. Did you reference the Evidence of Coverage, which was updated in April, for exclusions?

Yes/No?

2. Was this item purchased in 2024 for use in 2024? Yes/No?

3. Is this service or item for your personal use only? Yes/No?

4. Do you have an itemized receipt for each item or service? An itemized receipt includes date of

purchase, name of retailer, locat

ion of retailer, description of item and amount paid. Yes/No?

How to complete this form

When to use this form

1. Fill out this form if you are asking for reimbursement for covered fitness activity fees, supplies,

and wearable items. Do not use this form for any other reimbursement benefits.

2. Submit one form for each itemized receipt.

How to fill out this form

1. Complete each section. Print clearly in black ink only.

2. Read the statement in Section 3 below. Sign and date the form.

3. If someone other than the member is signing the form, you must have an Appointed

Representative form on file with the health plan. You can find an Appointment of

Representative form on AetnaMedicare.com

Where to send the completed form

1. Write your Aetna

member ID number on each itemized receipt and at the top of each page of

this form. Make copies of all these materials for your records. We will not return your

documents.

2. The itemized receipt must clearly state what was purchased, when it was purchased, and how

much it cost.

3. Mail this completed form and your original itemized receipts to the address on your Aetna

member ID card.

4. Or you can fax this

completed form with your original itemized receipts to 1-866-474-4040.

Things to remember

1. You must provide all the requested info. If you don't, it may take longer for us to pay you back.

Or we may not be able to pay you back at all.

2. Approved requests can take up to 45 days to send a check to the address we have on file.

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ECHS Category: SP07

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Section 1:

Member information (print clearly) – ALL fields required

Aetna member ID: Date of birth: Phone number (w/area code)

Last name, first name, middle initial Email:

Street address: City:

State: ZIP code:

Section 2:

Reimbursement request (information must match your itemized receipt)

Select the one reimbursement category below related to your itemized receipt for this submission.

Membership, activity or fitness fees

The itemized receipt must reflect only the current plan year. If your fitness activity or membership

spans multiple years, please ask for an itemized receipt that covers only the current plan year

portion. Payment must be made within the plan year.

Retailer name: Retailer location:

Date of purchase (mm/dd/yyyy): Amount paid:

/ /

Fitness or activity membership start date

(mm/dd/yyyy):

Fitness or activity membership end date

(mm/dd/yyyy):

/ /

ECHS Category: SP07

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Aetna member ID:

Activity or fitness supplies

You must include an itemized receipt. It must show the purchase was made within the plan

year and clearly reflect the name of the retailer. Include the retailer’s name and description of

the item in the box below. Purchases made with resellers, e.g., Facebook Marketplace, eBay

or garage/yard sales are not allowed.

Retailer name: Retailer location:

Date of purchase (mm/dd/yyyy): Amount paid:

/ /

$ .

If the amount of the purchase is over $100, you must also demonstrate that you personally

used the supplies or item purchased for a fitness activity. Provide a receipt showing the use of

the item if available. If you do not have a receipt, provide a complete description of your use of

the item in the boxes below.

Date of activity: Location of activity:

Description of activity when the supply was used:

Do you have an itemized receipt? If yes, submit a copy of the itemized receipt as proof with this

form. Please note if you also want to be reimbursed for this activity fee, submit a separate

fitness reimbursement form along with the original itemized receipt for the activity fee.

ECHS Category: SP07

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Aetna member ID:

Wearable items – fitness tracker

Fitness trackers are covered but limited to one per member per plan year. You must send

your itemized receipt for the fitness tracker with this form and describe how you’re using

the tracker for fitness.

Retailer name: Is the tracker registered to you:

☐Yes ☐No

Date of purchase (mm/dd/yyyy): Amount paid:

/ /

$ .

Type of fitness tracker (e.g., Apple Watch): Describe how you’re using the tracker:

Section 3: Signature is required

By signing and submitting this form, you are certifying that the information is true and correct and that the

services or items for which you requested reimbursement are for your sole use. You are certifying that you

understand that any person who knowingly files a claim containing any false or misleading information may be

guilty of fraud and is subject to criminal or civil penalties.

________________________________

Aetna member ID

__________________________________________________________ ____________________________

Member signature or authorized representative signature Date

ECHS Category: SP07

Section 4: Acknowledgment

Questions?

We are here to help. Just give us a call at the number on your ID card, 8 AM–8 PM, 7 days a

week.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations,

and conditions of coverage. Plan features and availability may vary by service area.

Important disclaimers

Any person who knowingly and with intent to injure, defraud or deceive 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 subjects such person

to criminal and civil penalties.

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