Get 1199SEIU National Benefit Fund 3NBF18 2013-2023

1199SEIU National Benefit Fund 330 West 42nd Street New York NY 10036-6977 www. 1199SEIUBenefits. org Tel 646 473-9200 Outside NYC Area Codes 800 575-7771 Statement of Claim for Medicare Part B Premium Reimbursement Filing Claims for Medicare Reimbursement 1. 3. If this is your first time filing a claim for Medicare Part B premium reimbursement you must include a copy of your Medicare Part B ID card with this form. 4. Member s signature X Date I attest that the person s for whom reimbursement is being submitted has active Medicare Part B coverage and may be required to submit proof that the coverage is still in effect. Claims may be filed on a quarterly semi-annual or annual basis. To ensure proper reimbursement please submit form SSA-1099 for each person for each claim year. 2. Eligible retirees may submit a claim for 50 of the basic Medicare Part B premium for the retiree and spouse. Claims may be filed on a quarterly semi-annual or annual basis. To ensure proper reimbursement please submit form SSA-1099 for each person for each claim year. 2. Eligible retirees may submit a claim for 50 of the basic Medicare Part B premium for the retiree and spouse. We will accept Medicare Part B premium claims for the current year and the two prior years. Eligibility is based on years of service and age at retirement. Check your Summary Plan Description for details. Please print clearly in black or blue ink 1. Member s full name Date of birth Month / Day Year Telephone 2. Spouse s full name 3. Address City Is this a new address Yes 4. Date of retirement 5. Check one Single State Zip code No Married Widowed Divorced Legally separated 6. Your Member ID Member s claim Check box for months paid Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Year 20 Spouse s claim including the month the claim is received* 7. Form will be returned if not signed* 3NBF18 5/13 1M Please complete and return to PO Box 2661 New York NY 10108-2661. We will accept Medicare Part B premium claims for the current year and the two prior years. Eligibility is based on years of service and age at retirement. Check your Summary Plan Description for details. Please print clearly in black or blue ink 1. Member s full name Date of birth Month / Day Year Telephone 2. Check your Summary Plan Description for details. Please print clearly in black or blue ink 1. Member s full name Date of birth Month / Day Year Telephone 2. Spouse s full name 3. Address City Is this a new address Yes 4. Date of retirement 5. Check one Single State Zip code No Married Widowed Divorced Legally separated 6. Spouse s full name 3. Address City Is this a new address Yes 4. Date of retirement 5. Check one Single State Zip code No Married Widowed Divorced Legally separated 6. Your Member ID Member s claim Check box for months paid Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Year 20 Spouse s claim including the month the claim is received* 7. We will accept Medicare Part B premium claims for the current year and the two prior years. Eligibility is based on years of service and age at retirement. Check your Summary Plan Description for details. Please print clearly in black or blue ink 1. Member s full name Date of birth Month / Day Year Telephone 2. Spouse s full name 3. Address City Is this a new address Yes 4. Date of retirement 5. Check one Single State Zip code No Married Widowed Divorced Legally separated 6. .