Welcome to Golden Vitality. This FREE program is designed to help you achieve a healthy lifestyle.
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- Marion Matthews
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1 olden Vitality Y L I F S H Welcome to olden Vitality. his F program is designed to help you achieve a healthy lifestyle. As a olden Vitality participant you re eligible to receive up to $200 in gym or fitness center membership reimbursements. eimbursement is also available for the cost of your membership to any yoga or tai chi studio or fitness classes at a local community college (not included in your fitness center membership). A complete list of reimbursable services and/or facilities is outlined on page three. Once enrolled in olden Vitality, please follow the submission instructions for reimbursement. Make sure to include a copy of your receipt noting payment of your fitness facility membership along with the request form. eimbursements are typically processed within 30 calendar days of receipt of all required materials. nrollment in the olden Vitality program is easy: You can fill out the enrollment form and mail or fax to Cigna or, for faster service, you may call to complete your enrollment over the phone e 08/13 H0354_752009e Accepted
2 Cigna, Cigna Medicare Services, Cigna Medicare Select Plus x (HMO), and the ree of Life logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Cigna HealthCare of Arizona, Inc. (CHC-AZ), and not by Cigna Corporation. Cigna Medicare Select Plus x (HMO) plans are offered by CHC-AZ under a contract with Medicare. As of the date of publication, Cigna Medicare Select Plus x plans are offered to employers and individuals in Maricopa County and certain zip codes within Apache Junction and Queen Creek, Arizona only. nrollment in Cigna Medicare Select Plus x depends on contract renewal. All models are used for illustrative purposes only. H0354_752009e Accepted e 08/ Cigna. Some content provided under license.
3 Y L I F enrollment form S H Last name, first name, middle initial: Address: City, State, ZIP code: Phone number: mail address (optional): You must be a Cigna Medicare Select (HMO) customer at the time the membership was purchased in order to be eligible for reimbursement. xpenses will be reimbursed only after services have been purchased and a request for reimbursement must be received in the same year that the membership was purchased. All requests must include an itemized receipt showing the purchase of the services (membership, fees or dues). Original receipts or photocopies are acceptable. If more than one purchase appears on the receipt, circle the expense you are requesting reimbursement for (please do not use a highlighter). All reimbursements will be paid to the olden Vitality participant and mailed to the address on file. You may request reimbursements on a monthly basis, however only one check per month per customer will be issued. Signature: Date: Please mail this completed form to: olden Vitality, P.O. Box 443, Irvine, CA You may also fax it to: For even faster service, you can enroll right over phone by calling (Y: 711) Monday Friday, 8 am 5 pm. Once enrolled in the olden Vitality program, we will send you a free program -shirt. Please indicate your size (circle one): M L XL 2XL 3XL ood health is comprised of many factors including preventive health care, nutrition, exercise and mental well-being. olden Vitality encourages a healthy lifestyle and provides educational opportunities and resources to help you make informed health care decisions. olden Vitality was designed exclusively for Cigna Medicare Select Plus x customers and is not available with any other Medicare plan. 2 H0354_752009e Accepted
4 Cigna, Cigna Medicare Services, Cigna Medicare Select Plus x (HMO), and the ree of Life logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Cigna HealthCare of Arizona, Inc. (CHC-AZ), and not by Cigna Corporation. Cigna Medicare Select Plus x (HMO) plans are offered by CHC-AZ under a contract with Medicare. As of the date of publication, Cigna Medicare Select Plus x plans are offered to employers and individuals in Maricopa County and certain zip codes within Apache Junction and Queen Creek, Arizona only. nrollment in Cigna Medicare Select Plus x depends on contract renewal. All models are used for illustrative purposes only e 08/ Cigna. Some content provided under license.
5 Y L I F reimbursement form S H Instructions: You must be enrolled in the olden Vitality program in order to request a reimbursement. Complete and sign the form below to request a reimbursement. Fax: , or Mail: olden Vitality, P.O. Box 443, Irvine, CA Section 1 Customer information (Please print) Last name, first name, middle initial: Address: City, state, ZIP code: Phone number: mail address (optional): Section 2 ype of reimbursement request Acceptable types of services/facilities ym/fitness center/health club Yoga/Pilates/ai Chi studio Martial arts studio/classes 1:1 Individual personal training session Fitness classes Date of purchase: Amount paid: ame and address of facility: You must be a Cigna Medicare Select (HMO) customer at the time the membership was purchased in order to be eligible for reimbursement. xpenses will be reimbursed only after services have been purchased and a request for reimbursement must be received in the same year that the membership was purchased. All requests must include an itemized receipt showing the purchase of the services (membership, fees or dues). Original receipts or photocopies are acceptable. If more than one purchase appears on the receipt, circle the expense you are requesting reimbursement for (please do not use a highlighter). All reimbursements will be paid to the olden Vitality participant and mailed to the address on file. You may request reimbursements on a monthly basis, however only one check per month per customer will be issued. Section 3 Certification and signature I certify that all expenses from the olden Vitality program for which I am requesting reimbursement have been incurred, have not been reimbursed and are not reimbursable under any other benefits. I understand that I am required to submit, in addition to this request, an itemized receipt from a fitness facility or an explanation of services received from a fitness professional. Cigna reserves the right to review any and all programs for which a customer requests reimbursement and may refuse reimbursement to that individual based on review of required criteria. Signature: Date: 3 H0354_752009e Accepted
6 Cigna, Cigna Medicare Services, Cigna Medicare Select Plus x (HMO), and the ree of Life logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Cigna HealthCare of Arizona, Inc. (CHC-AZ), and not by Cigna Corporation. Cigna Medicare Select Plus x (HMO) plans are offered by CHC-AZ under a contract with Medicare. As of the date of publication, Cigna Medicare Select Plus x plans are offered to employers and individuals in Maricopa County and certain zip codes within Apache Junction and Queen Creek, Arizona only. nrollment in Cigna Medicare Select Plus x depends on contract renewal. All models are used for illustrative purposes only e 08/ Cigna. Some content provided under license.
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