Prescription Drug Reimbursement Form
Use the Prescription Drug Reimbursement Form to file an eligible prescription drug claim reimbursement. See form for instructions.
Prescription Drug Reimbursement Form (PDF)
Member Record Request Form
Use this form to request your member record from AllWays Health Partners.
Member Record Request Form (PDF)
Member Reimbursement Claim Form
Use the Member Reimbursement Claim form to file an eligible medical or behavioral health claim reimbursement. See form for details and instructions.
Member Reimbursement Claim Form (PDF)
Bike Helmet Reimbursement Form
When you buy safety helmets for toddlers, children, and adults, AllWays Health Partners will reimburse 50% of the purchase price of one new helmet, per member, per calendar year up to a $15.00 reimbursement.
Bike Helmet Reimbursement Form (PDF)
Childbirth Education Reimbursement Form
Childbirth education classes, plus parenting and infant CPR classes, are available to you and your partner or support person free of charge at many primary care sites and hospitals.
Speak to the provider caring for you during your pregnancy or the facility where you plan to deliver about enrolling. If they do not offer a childbirth education program, AllWays Health Partners will reimburse you for the cost of these classes up to $130 per pregnancy. You can combine multiple classes up to the $130 limit per pregnancy. A Childbirth Education Form must be submitted to obtain the reimbursement.
Childbirth Education Reimbursement Form (PDF)
Breastfeeding Support Form
Breastfeeding support classes are also available free of charge at many primary care sites and hospitals. These classes are a support group for pregnant women, and they provide information about the benefits of breastfeeding, along with helpful tips, resources, and ways to manage common breastfeeding challenges.
Speak to the provider caring for you during your pregnancy or the facility where you plan to deliver about enrolling. If they do not offer a breastfeeding support program, AllWays Health Partners will reimburse you for the full cost of these classes. A Breastfeeding Support Form must be submitted to obtain the reimbursement.
Breastfeeding Support Form (PDF)
Personal Representative Designation Form
You have the right to choose one or more persons to act on your behalf with respect to the protected health information that pertains to you. If you would like to exercise this right, please complete and return this form to us.
English (PDF)
Spanish (PDF)
Continuity of Care at Cancer and Pediatric Facilities Notification Form
Members newly enrolled through a small employer group who began an active course of treatment for a serious illness prior to enrolling in an Easy Tier Hospital Network plan may be eligible to continue treatment at the lowest member cost-sharing tier (Tier 1).
Click here to determine if you are eligible.
If eligible, the
Continuity of Care at Cancer and Pediatric Facilities Notification Form (PDF) must be submitted prior to the start of treatment in the tiered network plan.
Weight Loss Reimbursement Form
The fastest way to submit a reimbursement request for your weight loss benefit is on the member portal,
allwaysmember.org. You can also download the form below and follow the instructions to submit your reimbursement request. The weight loss benefit varies by plan. Please check
allwaysmember.org for details about your plan.
Weight Loss Program Benefit Form and Instructions (PDF)
Fitness Benefit Reimbursement Form
Qualifying fitness facilities, programs or activities
The list includes, but is not limited to the following:
- Abington Athletic Club
- Anytime Fitness
- Beverly Athletic Club
- Boost Fitness
- Boston Athletic Club
- Boston Sports Club
- Cambridge Athletic Club
- Choice Fitness
- ClassPass memberships
- Club eX Fitness & Nutrition
- Crossfit
- Curves
- Equinox
- Get in Shape for Women
- Gold’s
- GymIt
- Healthtrax Fitness & Wellness
- Healthworks Fitness
- KoKo Fitclub
- LA Fitness
- Latitude Sports Club
- Mike’s Fitness
- Orange Theory
- Planet Fitness
- Pro-Fitness Plus
- Quincy Athletic Club
- Salem Fitness Center
- Shipley Fitness Center
- SplitFit
- The Clubs at Charles River Park
- Title Boxing Club
- Today’s Fitness
- VIP Fitness
- Weymouth Club
- Women’s Fitness of Boston
- Work Out World
- World Gym Worcester
- YMCA
Please note: Aerobic and exercise studios (Pilates, yoga, Zumba, etc.) are also included in this benefit
Non-eligible facilities, programs or activities include, but are not limited to, country clubs and social clubs, spas, and 1 on 1 sessions.