1199 Seiu Medicare Form PDF Details

The 1199 Seiu Medicare form is a document that you will likely need to fill out if you are a member of the 1199 SEIU union and are eligible for Medicare. This form can be used to enroll in Medicare or to change your enrollment information. In order to complete the 1199 Seiu Medicare form correctly, you will need to have some basic information about yourself and your Medicare coverage. The instructions for filling out the form are included on the document itself, so be sure to read them carefully before starting. Additionally, if you have any questions about completing the form, you can contact your local 1199 SEIU office for help.

QuestionAnswer
Form Name1199 Seiu Medicare Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names1199, 1199 medicare reimbursement form, 1199 eyeglasses reimbursement form, 1199seiu reimbursement

Form Preview Example

1199SEIU National Benefit Fund

330฀West฀42nd฀Street,฀New฀York,฀NY฀10036-6977฀•฀www.1199SEIUBeneits.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.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.

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.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:

 

/

 

/

 

Telephone: (

 

)

 

 

 

 

Month

 

Day

Year

 

 

 

2.

Spouse’s full name:

 

 

 

 

 

 

 

 

 

 

Date of birth:

 

/

 

/

 

Telephone: (

 

)

 

 

 

 

Month

 

Day

Year

 

 

 

3.

Address:

 

 

 

 

 

 

 

 

 

City:

Is this a new address?

4. Date of retirement:

 

/

 

Month

Yes

/

Day

State:

 

Zip code:

No

Year

5. Check one:

Single

Married

Widowed

Divorced

Legally separated

6. Your Member ID:

Member’s claim

Check box

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

for months paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s claim

Year 20____

Check box

for months paid

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

Year 20____

Medicare Part B reimbursement will not be made for future time periods. Reimbursement will only be made up to and

including the month the claim is received.

7. 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. Form will be returned if not signed.

Please complete and return to:

1199SEIU National Benefit Fund

3NBF18฀•฀5/13฀•฀1M

PO Box 2661

New York, NY 10108-2661

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Pay close attention when filling out this document. Make sure all required fields are filled out properly.

1. First of all, once filling out the statement claim premium reimbursement, start with the page containing next blank fields:

fund medicare reimbursement completion process detailed (part 1)

2. After performing the last section, go on to the subsequent step and complete all required particulars in these blank fields - Spouses claim, Check box, for months paid, Jan, Feb Mar, Apr May, June, July, Aug, Sept, Oct, Nov, Dec, Year , and Medicare Part B reimbursement will.

Filling in part 2 of fund medicare reimbursement

Be really careful while filling out for months paid and Year , as this is where a lot of people make errors.

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