The Club-Fitness, Heath & Spa 80 Middlesex Street Lowell, MA 01852 Phone: 978-441-1166 E-Mail: info@theclub-lowell.com

 

Request A Receipt for Insurance Reimbursement

We appreciate your help with keeping our membership records up to date...

Name:		Membership #:
Phone:		E-Mail:
Address:		Unit#:
City:		State:
Zip Code:
I Need a ?	Contract Receipt
	Receipt dates (MM/DD/YY) to (MM/DD/YY)
Who is your Health Insurance Provider?		Select One Blue Cross/Blue Shield Cigna Fallon Community Health Plan Harvard Pilgrim Other (Please Specify)
Specify:
*Please note: Requests for receipts take 3 business days to process and will be left for you to pick up at the front desk.

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