Gym Reimbursement Form

Gym Reimbursement Form (Service To Seniors HMO) -
Please read the instructions and fill out the form, print and sign it.   Please include your signed Gym reimbursement form and appropriate receipts in an envelope addressed to:
                          Inter Valley Health Plan
                          Claims Department/Gym
                          P.O. Box 6002
                          Pomona, CA 91769-6002

Please use this form for mobile or online submissions

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