To claim reimbursement under the NYSHIP Empire Plan gym reimbursement form, you need to log at least 50 gym visits during a single six-month reward period, complete the ExerciseRewards Reimbursement Request Form together with a Fitness Center Member Verification (FCMV) form, and mail or email both with your visit log and proof of payment to the ExerciseRewards processing center. Everything has to arrive within 90 days after your benefit plan year ends, and payment typically follows within 30 days after the payout period closes.
Gather These Three Documents First
Before you open the form, put your hands on everything the reviewer will look for. Missing pieces are the single most common reason claims come back unpaid.
- Visit documentation. Either a computer-generated printout from your gym showing each check-in date during the reward period, or the visit log on page 2 of the reimbursement form, signed or stamped by a staff member on each visit.1Hamilton-Fulton-Montgomery BOCES. Gym Reimbursement Form
- Proof of payment. A gym receipt, gym statement, or a credit card or bank statement showing what you paid. The document must include the date, your name, the amount, and the gym’s name, address, and an authorized signature. A membership card by itself does not count.2Hamilton-Fulton-Montgomery BOCES. Gym Reimbursement Form
- Fitness Center Member Verification (FCMV) form. A separate one-page form on which a facility representative confirms that you have accepted liability and risk for using the gym. This is a membership attestation, not a visit log, and the facility signature line must be filled in.3Empire Blue. Fitness Facility Member Verification Form
The FCMV may prompt a follow-up request for a copy of your fitness facility agreement, so keep that document within reach.3Empire Blue. Fitness Facility Member Verification Form
Where to Get the Form and What Goes Where
Download the ExerciseRewards Reimbursement Request Form by logging in at empireblue.com, opening the Health & Wellness Center under the Care section, and selecting the reimbursement forms in the Gym Reimbursement area.4Hamilton-Fulton-Montgomery BOCES. Gym Reimbursement Form with Facility Verification Some employers also make the form available through their benefits portal or HR office.
The form asks for a short set of details:
- Your Health Plan ID, printed on your Empire Plan insurance card. One transposed digit and the system cannot match your claim to your coverage.
- Your name, exactly as it appears on your proof of payment.
- Your fitness facility’s name and address, matching the receipt or statement you’re attaching.
- The start and end dates of the membership term you’re claiming.
- The 50 visit dates, if you’re using the built-in log rather than a gym-generated printout. Page 2 has numbered spaces; write each date in month/day/year format.
Mismatches between the facility name on the form and the name on your proof of payment are one of the most common reasons claims are kicked back. Read the two documents side by side before you sign.
The 50-Visit Rule the Form Is Built Around
Each calendar year is split into two reward periods: January 1 through June 30, and July 1 through December 31. You need at least 50 workout sessions during a single period to qualify.5Research Foundation for SUNY. Fitness Center Visit Submission Form There is no partial payment at 40 or 49 visits.
Only one session counts per calendar day, and there must be at least eight hours between logged sessions.5Research Foundation for SUNY. Fitness Center Visit Submission Form You cannot double up on a Saturday to make up for a missed weekday.
Virtual workouts count if you use a subscription-based platform. Proof takes the form of a printed visit or attendance log with dates and times, screen captures of your session history, or both.5Research Foundation for SUNY. Fitness Center Visit Submission Form The one-session-per-day rule still applies.
If your gym is an Active&Fit participating facility, you can skip the form entirely; those locations submit visit data to ExerciseRewards automatically.5Research Foundation for SUNY. Fitness Center Visit Submission Form
Make Sure Your Gym Qualifies
Not every place with equipment counts. To qualify, a facility must:6Research Foundation for SUNY. Gym Reimbursement – SUNY RF
- Offer monthly memberships or collect regular dues.
- Be open to the public rather than restricted beyond ordinary membership.
- Have staff on site during operating hours who oversee operations and attend to members. Class instructors alone do not satisfy this.
- Run regularly scheduled cardio, flexibility, or weight-training programs, or offer virtual on-demand and livestream classes.
Country clubs, tennis clubs, social clubs, sports teams and leagues, weight-loss clinics, spas, and rehabilitation or physical therapy providers do not qualify.6Research Foundation for SUNY. Gym Reimbursement – SUNY RF Personal training sessions, coaching lessons, and gym access bundled into rent or HOA fees are also outside the program. Equipment purchases such as weights, shoes, or vitamins are never covered, even if the qualifying gym is the one selling them.
How and Where to Submit
You can submit by mail or email. By mail, send the completed reimbursement form, the FCMV form, your visit documentation, and proof of payment to:3Empire Blue. Fitness Facility Member Verification Form
ExerciseRewards
P.O. Box 509117
San Diego, CA 92150-9117
By email, send scanned copies of every document to fitness@exerciserewards.com with the subject line “Gym reimbursement request.”1Hamilton-Fulton-Montgomery BOCES. Gym Reimbursement Form Attach the reimbursement form, the FCMV form, the visit log or printout, and the proof of payment.
You can send the packet as soon as you reach 50 visits; there is no need to wait for the reward period to end. All reimbursement requests must arrive within 90 days after the end of your benefit plan year. Anything received after that window is ineligible.7Hamilton-Fulton-Montgomery BOCES. Gym Reimbursement
After You Submit
Processing takes up to 30 days after the payout period ends.7Hamilton-Fulton-Montgomery BOCES. Gym Reimbursement If the administrator asks for extra documentation, such as a copy of your facility agreement, that timeline resets. You can check status through the empireblue.com member portal.
The reimbursement is generally treated as taxable income. It typically appears in Box 1 of your W-2 with wages, tips, and other compensation, and your employer may detail it separately in Box 14 or on an attached statement. Plan for a modest tax hit rather than treating the payout as a net gain.
Common Reasons Claims Get Denied
Most rejections trace back to the same paperwork errors:
- Fewer than 50 visits logged. Even 49 pays nothing. Count before you submit.
- Missing or unsigned FCMV form. A blank facility signature line triggers an automatic denial.3Empire Blue. Fitness Facility Member Verification Form
- No proof of payment. A membership card is not enough; you need a receipt or statement showing money changed hands.
- Non-qualifying facility. Country clubs, sports leagues, and gyms without on-site staff or scheduled programming will not process.
- Name or Health Plan ID mismatches between the reimbursement form and the proof of payment.
- Late submission. Anything arriving more than 90 days after your benefit plan year ends is ineligible.7Hamilton-Fulton-Montgomery BOCES. Gym Reimbursement
One warning worth keeping in mind. Submitting fabricated visit records or falsified attendance logs is insurance fraud under New York Penal Law Article 176, a criminal offense that can range from a misdemeanor to a felony depending on the dollar amount.8New York State Unified Court System. New York Penal Law 176.15, 176.20, 176.25, 176.30 – Insurance Fraud in the Fourth, Third, Second, and First Degree The exposure is out of all proportion to a few hundred dollars of reimbursement.