myHT 2.1

Wellness Reimbursement Form

The Wellness Benefit is payable at 100% with no deductible, and not subject to reasonable and customary provisions. The maximum benefit is $200 per health year, (June 1 - May 31), for employee’s coverage. Please note that Human Resources will contact you for verification of your request to use the Wellness Benefit.

Your Name:
Your Supervisor:
Today's Date:
Employee Department:
Total Amount Spent on Item
Description of Purchase:

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