Get Asrs Reimbursement Of Medical Andor Dental Cost Form

Completing the Asrs Reimbursement Of Medical Andor Dental Cost Form online is essential for retirees and long term disability participants seeking reimbursement for medical and dental premiums. This guide provides clear instructions to help you navigate and fill out each section accurately.

Follow the steps to complete the form seamlessly.

1. Click ‘Get Form’ button to download the form and access it for editing.
2. In Section 1, carefully enter your Social Security number, full legal name, date of birth, mailing address, and daytime telephone number. Ensure all information is accurate to avoid processing issues.
3. For Section 2, indicate your ASRS status by checking the appropriate box, specifying whether you are a retiree or a long term disability participant. If you are a long term disability participant, also indicate your Medicare eligibility.
4. In Section 3, input the required details about your insurance coverage. This includes the policy holder’s name, Social Security number, date of birth, and the effective date of coverage for you and any dependents.
5. Section 4 is where you provide the six-month reimbursement totals. Enter the monthly premium amounts for both medical and dental coverage, detailing your out-of-pocket expenses. Ensure each month's information is listed separately.
6. In Section 5, your employer representative must complete their information, sign, and date the form. This step is crucial for verifying your claim.
7. After completing all sections, save any changes made to the form. You can download, print, or share the filled-out form as required.

Begin filling out your Asrs Reimbursement Of Medical Andor Dental Cost Form online today!