Medicare Part B Reimbursement Request Form
- Reimbursement Distribution
< Previous Step
- In the Coverage Period section, enter the first of the month in which you are eligible for Medicare Part B this year and enter the last day of the year. For example, if you are eligible for Medicare Part B on January 1, 2019, you will fill in 1/1/2019 to 12/31/2019.
- Submit a copy of your Social Security cost-of-living adjustment (COLA) statement as proof of your payment (usually mailed starting in November the year before the adjustment becomes effective) or any other documentation showing your annual Medicare Part B premiums.
- If Medicare Part B premiums are not deducted from your Social Security check, submit a copy (front and back) of the cleared check or a bank/credit card statement that indicates your Medicare Part B premium payment.
I am requesting reimbursement of the following paid Medicare Part B premiums:
Please attach documents showing your monthly Medicare Part B premium(s) paid. The documents must include the period for which you have
paid, proof of the premium payment, the name of the insurance company, the type of expense (Medicare Part B premiums), and the covered
participant’s name. If you are attaching a copy of a cleared check, please submit an attachment of the front of the check.
*These fields are required to complete the above form.
Thank you for your submission. If you have selected to receive your reimbursement by mail, you should expect to receive your reimbursement
check in the next 3-5 business days. If you chose to receive your reimbursement by direct deposit into your bank account, you should expect
your reimbursement deposit to be made in the next 2-3 business days.
If you have any questions or concerns, please call us at 1-877-648-9641.