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08-702-033b Rev. 06 1/11 It Fits Reimbursement Form Subscribers are eligible for reimbursement once per bene t year. For more information about other tness discounts visit fchp.org. Mail completed form to Claims Department P. O. Box 15121 Worcester MA 01615 Subscriber information Note The subscriber is the primary health insurance policyholder not necessarily the person requesting reimbursement. Subscriber s signature Date A bene t year is the 12-month period during which your annual health...
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