Weight-Loss Reimbursement Request
PLEASE PRINT ALL INFORMATION CLEARL
Y
To verify this reimbursement is offered within your plan, or for more information, please sign
in to MyBlue at bluecrossma.org 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.
Subscriber Information (Policyholder)
Identication Number on Subscriber ID Card
(including rst 3 characters)
Subscriber’s Last Name First Name Middle Initial
Address – Number and Street City State ZIP Code
Employer’s Name
Claim Information
Member’s Last Name First Name Middle Initial Date of Birth (MM/DD/YY)
Claim is for (choose one and color in the entire box):
Subscriber (policyholder)
Spouse (of policyholder)
Ex-Spouse ___________________________________________________________
Dependent (up to age 26)
Other (specify)
Name, Address, and Phone Number of Qualied Weight-Loss Program
Total dollars requested: $ ________________________________________________________
Monthly program participation fee: $ ______________________________________________
Year Fees Paid:
Blue Cross Blue Shield of Massachusetts will make a reimbursement decision within 30 calendar days of receiving a completed request form.
Reimbursement is sent to the member's address on le with Blue Cross. Reimbursement may be considered taxable income, so consult your
tax advisor.
Certication and Authorization (This form must be signed and dated below.)
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. I enrolled in the qualied program with the full intention of using such program. I understand that Blue Cross Blue Shield of
Massachusetts may require proof of payment for a reimbursement decision. I authorize the release of any information about my qualied
weight-loss program to Blue Cross Blue Shield of Massachusetts.
Subscriber Signature: Date (MM/DD/YY)
Complete this form and mail it to:
Blue Cross Blue Shield of Massachusetts Local Claims Department
PO Box 986030
Boston, MA 02298
Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual
orientation, or gender identity.
ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que gura en su tarjeta de identicación (TTY: 711).
ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
® Registered Marks of the Blue Cross and Blue Shield Associataion. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc.,
or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
001291618 (2/22)
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