Member resources & forms

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, Mass General Brigham Health Plan 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)

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.

The fastest way to submit a reimbursement request for your fitness benefit is on the Member Portal. You can also download the form below and follow the instructions to submit your reimbursement request. The fitness benefit varies by plan. Please check Member Portal for details about your plan.

Fitness Benefit Coverage Form and Instructions (PDF)
 

Qualifying fitness facilities, programs/subscriptions or activities

The list includes, but is not limited to the following:

• Abington Athletic Club
• Anytime Fitness
• Apple Fitness+
• Beachbody On Demand
• Beverly Athletic Club
• Boost Fitness
• Boston Athletic Club
• Boston Sports Club
• Bowflex Subscriptions
• Cambridge Athletic Club
• Choice Fitness
• ClassPass memberships 
• Club eX Fitness & Nutrition
• Core Yoga Subscriptions
• Crossfit
• Curves
• DDP Yoga Subscriptions
• Equinox
• Get in Shape for Women
• Gold’s
• GymIt
• Healthtrax Fitness & Wellness
• Healthworks Fitness
• KoKo Fitclub
• LA Fitness 
• Latitude Sports Club
• Mike’s Fitness
• Mirror Subscriptions
• Orange Theory
• Peloton Subscriptions
• 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
• Worlds Gym
• YMCA

Please note: Aerobic exercise studios (Pilates, yoga, Zumba, etc.) and virtual fitness subscriptions 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. DVDs, equipment, and YouTube subscriptions are not covered.

Use this form to authorize Mass General Brigham Health Plan to release your Protected Health Information (PHI) to a designated recipient.

Authorization to Release Protected Health Information (PDF)

Use the Member Reimbursement Claim form to file an eligible behavioral health reimbursement. See form for details and instructions.

Member Behavioral Health Reimbursement Claim Form

Use the Member Reimbursement Claim form to file an eligible medical reimbursement. See form for details and instructions.

Member Medical Reimbursement Claim Form

Use this form to request your member record from Mass General Brigham Health Plan.

Member Record Request Form (PDF)

Use the Prescription Drug Reimbursement Form to file an eligible prescription drug claim reimbursement. See form for instructions.

Prescription Drug Reimbursement Form (PDF)

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.

For Commercial members

Authorize a Personal Representative: English | Español

For MassHealth/Mass General Brigham ACO members only

Authorize a Personal Representative: English | Español

Travel Benefit Reimbursement Form

This form can be used by members whose plans include a travel benefit from their employer. The travel benefit helps cover certain costs for members who need to travel in order to obtain services covered under their plan when state law does not allow a provider to administer such coverage in the state that the member resides.

See form for details on eligibility and instructions for reimbursement.

Travel Benefit Reimbursement Form (PDF)

The fastest way to submit a reimbursement request for your weight loss benefit is on the Member portal or our Member app. 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 Member Portal for details about your plan.

Weight Loss Program Benefit Form and Instructions (PDF)
 
Qualifying weight-loss programs

• Weight Watchers (WW)
• Jenny Craig
• Noom

 
Please note: The weight loss program benefit does not cover food, nutritional supplements, or enrollment/registration fees.