
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