Sample Certificate - cert.companyname

* NOTE: Some employer groups may not offer this program, please check with your Human Resources department before participating in this program.
Allow 8 to 10 weeks for your reimbursement to be processed.
Reimbursement requests that are incomplete may be delayed.

1	HealthAmerica HMO HealthAssurance PPO HealthAssurance POS Advantra
2	Member ID: DBMEMBERID Name: DBNAME Age: DBAGE Primary Subscriber Name: DB PRIMARY SUBSCRIBER NAME   Address: DBADDRESS   Phone: DB PHONE City: DC CITY State: DB STATE Zip: DB ZIP Employer Name (if applicable): DB EMPLOYER ID
3	Type of Program: arthritis management heart health smoking cessation   asthma education nutrition education stress management   back care lung disease weight management*   diabetes education prenatal education wellness education   family wellness safety education women's wellness Program Name:    Mediterranean Wellness      Start Date:    DBSTARTDATE      Location:    Webcast    Please rate the program you have just taken:
4	Total Expected Reimbursement:           $200           Please attach proof of payment (copy of receipt or cancelled check). Your refund request cannot be process without this..
5	*Weight management: Please include proof of payment (copy receipt or cancelled check). There is a maximum reimbursement of $350 per member per calendar year (January through December) for approved weight management programs. It is not necessary to submit your weigh-in book.
6	Preauthorized private prenatal education: List instructor's name, address, phone and certification numbers
7	I verify that the member named above has attended at least 80% of the program listed above. Instructor's Signature: Date: TODAYSDATE Instructor verification is required to receive reimbursement.
8	Mail completed request to: For Central and Southeastern PA: HealthAmerica Health Education Reimbursement PO Box 7089 London KY 40742 For Western PA, Ohio and WV: HealthAmerica Health Education Reimbursement PO Box 7088 London KY 40742

HealthAmerica Learn & Earn Refund and Discount Program*

1. Select a class from an approved facility. Choose a course or program that falls into one of our approved class
   categories offered by one of our approved facilities. Register and pay the program fee. Keep a copy of your receipt.
   You will need it to submit with your request for reimbursement. Download the most current list of approved facilities
   at www.healthamerica.cvty.com or contact HealthAmerica Customer Service using the number on the back of your
   card.
   
   
2. Obtain a Reimbursement Request Form. At the first session of your program, show your form to your instructor so
   that he/she is aware that you will need attendance verification at the end of the program.
   
   Obtain a Reimbursement Request Form from one of the following:
   
   
   • Your human resources department
   • Download from www.healthamerica.cvty.com
     
     
3. Attend at least 80% of the program sessions.
   
   
4. Obtain instructor signature. At the last session of your program, have your instructor sign the form in the
   appropriate space, verifying your attendance of at least 80% of the program sessions.
   
   
5. Complete the form.
   • Print all information clearly and legibly.
   • Indicate if you have HealthAmerica HMO, HealthAssurance PPO, HealthAssurance POS or Advantra
   • Verify your ID number, group number, and your name and address.
   • Identify the course or program you completed, location, and the amount of reimbursement requested.
   
   
6. Special requirements for weight management programs. HealthAmerica, HealthAssurance and Advantra will
   reimburse up to $350 per calendar year per member for the educational components of an approved group weight
   management program. If a class spans two calendar years, the reimbursement limit will be based on the program start
   date.
   
   Weight Watchers reimbursement requirements
   
   
   • A cash receipt must be submitted if payment for the program was paid by cash.
     
   • Weight Watchers Online participants must submit a copy of their Weigh-In Tracker printed from WW Online to
   verify participation in the program. This will replace Instructor Signature in #7 of the form.
   • At-Home Kits are not eligible for reimbursement. Members receive discounts by accessing these programs via
   www.healthamerica.cvty.com.
   
   
7. Mail your request. Mail the completed form, a copy of your receipt, and other program documents to the appropriate
   address (located on the front of this form). Keep a copy of everything for your records. Requests must be received
   within 12 months of the program completion date to be eligible for reimbursement.
   
   
8. Allow 8 to 10 weeks for your request to be processed.

* NOTE: Some employer groups may not offer this program, please check with your Human Resources department before participating in this program.

Acknowledgement
OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD 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.