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Get Irmaa Reimbursement 2019

Adjustment Amount (IRMAA). Submit this completed form and required documentation to: NYS Department of Civil Service Employee Benefits Division Attn: IRMAA Accounting Alfred E. Smith State Office Building Albany, NY 12239 ENROLLEE INFORMATION Name: Last, First, MI Social Security Number (Last) (First) (MI) Enrollee Mailing Address Address Daytime Telephone Number (with area code) Apt.# City State Zip Code check here if this is a change of address DEPENDENT INFORMATION If you are a.

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