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You must sign and date this application. You must also submit with your application a copy of your Medicare card (the red, white and blue card) and a copy of your Form SSA-1099 issued by the Social Security Administration. Once a retiree enrolls in Medicare Part B, attains age 65 or is disabled as defined by the Social Security Administration, the member may be entitled to a partial or full refund of their monthly Medicare Part B premiums based upon health plan in which they are enrolled. 1. To.

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