Acme South Only: Tri-State Retention Benefits Reimbursement Application
- Union Yes
- Oct 14
- 2 min read
Updated: 6 days ago
HOW TO FILE A CLAIM FOR RETENTION BENEFITS REIMBURSEMENT
To assure proper identification and prompt payment, Part A should be completed, and the participant should sign the release of information block.
You may submit a fully itemized receipt on the provider's letterhead, or the provider can check the boxes in Part B for the services/ supplies being provided, furnish all the receipts required, sign, and date the Part B claim form.
The Form and necessary receipts are to be submitted to the UFCW Tri-State Health and Welfare Fund address shown on the front of the form for processing and payment.
FITNESS MEMBERSHIP
$200 per Calendar year.
Fitness Club representatives must complete and sign a reimbursement application form. Must submit receipt for yearly membership fee. Membership fees for a full-service health club with cardio and strength training equipment, such as treadmills, stationary bikes, weight machines, and free weights. It does not include home training or the purchase of any training equipment or devices.
ACUPUNCTURE
$75 per service, to a maximum of $200 per Calendar Year. Reimbursement is limited to services by a state-licensed Acupuncturist.
MASSAGE THERAPY $75 per service, to a maximum of $200 per Calendar Year. Reimbursement is limited to services by a Certified Massage Therapist (CMТ). Receipt must include the signature and certification number of the Massage Therapist.
Participants eligible to utilize this benefit must submit receipts to the Fund Office no later than June 30 of the year following the calendar year in which the expense was incurred. For example, reimbursable expenses incurred between January 1 and December 31 are eligible for reimbursement if submitted by June 30 of the following calendar year.
This benefit is for the participant only**
Eligibility Requirements, are for all active full-time employees and all active part-time employees of Acme South with eighteen (18) months of service.