I attest that the information I provided is true and accurate,
and the services were received and paid for in the amount requested
as indicated above. I acknowledged that if any information on this form is
misleading or fraudulent, my coverage may be canceled and I may be subject to
criminal and/or civil penalties for false health care claims. I also understand
that Inter Valley Health Plan may request any additional information it deems
necessary to verify that services were received and payment was made. If at any
time during the year you cancel your gym/health club membership, you agree to contact the Plan.
Sorry, your record shows you are not eligible.
If you have any questions, please contact us.
Sorry, you indicate you are ready to upload your proof of payment now.
Please upload it now.
If you choose to upload your purchase of proof, please upload one proof for each month you request.