Wellness Wallet Reimbursement Form

Wellness Wallet Reimbursement Form

Wellness Wallet Reimbursement Form

Wellness Wallet Reimbursement Form

Kennebec Eye Care​​​​​​​, P.A.

2021 Wellness Wallet Member Reimbursement Form

If you are not sure if your expense is eligible for reimbursement, please call Martin's Point Generations Advantage Member Services at 1-866-544-7504. See instructions on the bottom of this sheet. Please visit MartinsPoint.org/WellnessWallet or call Member Services for details. Please know this is not a guarantee of coverage. A final determination is made at the time of claim processing.

A. Member Information

Member Name

Member Date of Birth

Martin's Point Member ID Number

B. Please indicate which 2021 service you wish to be reimbursed for:
NOTE: Reimbursements are only available for items or services purchased in 2021.
*Please note some items and services have restrictions.

Naturopathic services

Eyewear

Fitness

Nutrition/Dietary

Face Masks

Other Covered Item/Service

Service Provider/Store of Purchase

Date(s) of Service

Total Charge of Service

Amount Paid

C. Signature

D. Receipts

E. Proof of Payment

Please complete all fields of this form and PROVIDE AN ITEMIZED RECEIPT AND PROOF OF PAYMENT. Incomplete information may result in a delay or denial of your claim.

Upon completion return to:
Martin's Point Generations Advantage
Claims Department
PO Box 11410
Portland, ME 04104-9863

If additional information is not needed, payment should be received within four to six weeks. To be eligible for payment, the date of service or purchase must be in 2021 and you must submit your claim by March 31, 2022.

Please note: We will reimburse in full (up to the 2021 Wellness Wallet Limit) if your fitness/gym membership extends into the 2022 calendar year.
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