Wellness Reimbursement Form - Unity Health Insurance

Wellness Reimbursement Form
Name
Address
City State Zip Code
Member ID Number:
Person Code
Date of Birth (mm/dd/yyyy)
ACTIVITY FOR REIMBURSEMENT (CHECK ALL THAT APPLY)
If the activity you have selected qualifies for both HealthyU and Fitness First & More
you will be reimbursed for both programs based on your available reimbursement amount.
Health Education Class
Class Name
$
Amount Paid for Class
Facility
Date(s) of Class
Community Supported
Agriculture (CSA)
Instructor’s Signature
Name of FairShare CSA Coalition Member Farm
This student had 75%
or better attendance
$
Amount You Paid
for Your Share
Integrative Medicine
SERVICE YOU RECEIVED: Acupuncture Feldenkrais Healing Touch Massage/Therapy
and Bodywork
SERVICE RECEIVED AT:
$
Amount Paid for Service
Weight Management
Overall Weight Loss Number of Meetings Attended if participating in Weight Watchers meetings Total Amount Paid
$
Preventive Health
Preventive Health Service Received
Date Service Received
Preventive Health Service Received
Date Service Received
Preventive Health Service Received
Date Service Received
Preventive Health Service Received
Date Service Received
Practitioner’s Signature:
TO RECEIVE YOUR REIMBURSEMENT, COMPLETE THE FOLLOWING STEPS:
1. Review the rules for reimbursement
and fill out the reimbursement form
2. Attach your itemized receipt(s) or
required documentation
For more information about Fitness First & More
and HealthyU, visit chooseunityhealth.com.
3. Mail the reimbursement form and the
itemized receipts and/or required
documentation to:
Unity Health Insurance
Attn: Wellness Reimbursement
840 Carolina Street
Sauk City WI 53583
Date
UH01249 (1212)
Unity Health Plans Insurance Corporation

RULES FOR REIMBURSEMENT
Health Education Classes
Classes must be held at one of Unity’s participating hospitals
or clinics or other approved vendors and fall into one of the
following categories:
• Pregnancy and parenting
• Nutrition
• Weight management
• Special activities, e.g. yoga and Pilates
• CPR and First Aid
• Stress and Anxiety Management (e.g. mindfulness and
meditation)
• Tobacco use cessation
You may also receive reimbursement for membership in the
Children & Adults with Attention-Deficit/Hyperactivity Disorder
(CHADD®) program.
Requirements for reimbursement:
• Attend 75% of the classes of an approved program or if
purchased an unlimited pass you must attend at least 10 classes
in one month
• Be a Unity member at the completion of the class
• Complete the Wellness Reimbursement Form and have the
instructor sign it
• Mail the completed reimbursement form to Unity upon finishing
the class
* For the CHADD® program you will also need to submit the pre and post surveys as well
as a copy of the welcome letter from CHADD®.
Community Supported Agriculture (CSA)
Reimbursement Requirements
• Purchase a produce share from a FairShare CSA Coalition
member farm
• Be a Unity member on the date of purchase
• Complete the Wellness Reimbursement Form
• Mail the completed reimbursement form and one of the
following proofs of payment to Unity in the same calendar
year it was purchased:
– Itemized receipt from the farm
– Copy of an email from the farm acknowledging your
purchase (must include the amount you paid for your share
and date of purchase). Please Note: e date the email was
sent to you does not constitute the date of purchase.
– A copy of your canceled check or credit card receipt
(If you are splitting a produce share, be sure your name is
included on the proof of payment. Also, indicate the amount you
paid for your portion of the share on the reimbursement form.)
Please Note: If you have completed your health risk assessment
and/or biometric measurements (through a Unity screening or
by submitting a biometric exception form), this information will
automatically be updated by Unity. You don’t need to complete
this form for either the HRA or biometrics portions of the
HealthyU program.
Integrative Medicine Reimbursement Requirements:
• Receive one of the following eligible integrative medicine services:
– Acupuncture
– Feldenkrais
– Healing Touch
– Massage erapy and Bodywork
• Receive the service from an eligible provider
– UW Health Integrative Medicine
– Unity Fitness First Participating Health Club
– Unity Health First Vendor listed under Massage erapy,
Acupuncture and Spa Services
• Be a Unity member on the date of service
• Complete the Wellness Reimbursement Form
• Mail the completed reimbursement form and your itemized
receipt to Unity upon receiving the service. e itemized receipt
must include your name, the provider’s name, address, telephone
number, license number, description of service received, date of
service and the amount paid. Tips and gratuities are not
reimbursable.
Weight Management Reimbursement Requirements
• Participate in Weight Watchers® meetings or Weight Watchers®
online for three consecutive months or participate in all
Diet-Free® meetings
• Be a Unity member at the completion of your participation
• Complete the Wellness Reimbursement Form
• Mail the completed reimbursement form, a copy of your
personal weight tracker (if participating in Weight Watchers®)
or receipt of payment (if participating in Diet-Free) to Unity
Preventive Health Screenings Reimbursement Requirements
is form only needs to be completed if you received the required
preventive service from a non-participating provider.
• Receive a required preventive health screening based on the
chart below
• Complete the Wellness Reimbursement Form and have your
practitioner sign and date it
• Mail the completed reimbursement form to Unity
Female
Male
18-20 21-25 26-44 45-49 50-64 65+ 18-34 35-44 45-49 50-64 65+
Biometrics X X X X X X X X X X X
Chlamydia Screening X X
Colorectal Cancer
Screening
X X X X
Dental Exam X X X X X X X X X X X
Eye Exam X X X X X X X X X X X
Flu Vaccination X X X X X X X X X X X
Mammogram X X
Office Visit with Primary
Care Provider
X X X X X X X X X X X
Pap Test X X X X X
Pneumonia Vaccination X X
Minimum Number
Needed to
Complete Challenge
4 4 3 3 3 3 3 3 3 3 3
Minimum number of preventive screenings are based on your age as of January 1.