Get Medicare Reimbursement Account Claim Form And Instructions

Filling out the Medicare Reimbursement Account Claim Form can be straightforward and efficient. By understanding each section of the form, users can ensure they receive the reimbursements they are entitled to without unnecessary delays.

Follow the steps to accurately complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the account holder information section, enter the first and last name of the account holder clearly. If submitting for a spouse or covered dependents, complete a separate form for each individual.
3. For claims related to out-of-pocket expenses, determine how your Medicare Part B premiums are paid. Select the appropriate option by checking the first box if premiums are automatically deducted from your Social Security or Annuity check. Alternatively, check the second box if you pay these premiums on an after-tax basis.
4. Input your service start date. This could be January 1 of the year you are requesting reimbursement, your effective date if it is after January 1, or the first of the month(s) for those who pay monthly or quarterly.
5. Similarly, provide your service end date, which could be December 31 of the year you are requesting reimbursement or the last day of the month(s) if payments are made monthly or quarterly.
6. Fill in the total annual or monthly/quarterly amount for your Medicare Part B payment.
7. Attach proof of payment for your Medicare Part B premiums. Documents must verify the payment date, the name of the Medicare Part B account holder, the insurance carrier's name, the type of expense, and proof of payment such as a cleared check, bank statement, or credit card statement.
8. Make sure you keep copies of all original documents you submit for your records.
9. Finally, certify that the information on the form is accurate and complete, then submit your claim via fax or mail as instructed.

Complete your Medicare Reimbursement Account Claim Form online today to ensure timely reimbursement.