Reimbursement Request for WGT Members

If you are a member of WGT and a Pro Health Advisor participant you are eligible for reimbursement of some of your medical care expenses including copays and deductibles. The expense must be related to a specific condition for which PHA is assisting. A completed receipt from the provider must accompany this form. Send the documents to the address at the bottom of the form (Appleton, WI) for the quickest turn around. Email, postal or FAX is perfectly acceptable.

For copays, ask your Advisor to send you an authorization for your provider to bill WGT full charges instead of asking you for a copay.