Tiaa-Cref Application For Medicare Part B Premium Reimbursement
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1
2UBO USE ONLY
st
RET/TERM: _________________ 1
Payment Year: ________
EE Med Part B: _______________ PYC’s:________________
SP/DP Med Part B: ____________
(MEMBERS OF TIAA-CREF PENSION SYSTEM)
APPLICATION FOR MEDICARE PART B PREMIUM REIMBURSEMENT
RETIREE INFORMATION:
Social Security Number: _____-_____-_____
Name:
___________________________________________
Date of Birth:
Address:
Apt. No
City
State
Zip Code
Email Address:
Telephone No. (
)
College Retired From:
Retirement Date:
Marital Status:
Single
Married
Divorced
Widowed
Domestic Partner
Date of Event:
Do you receive a monthly Lifetime Income Annuity from TIAA-CREF?
Yes
No
Are health insurance premiums withheld from your TIAA-CREF pension check?
Yes
No
No Premium Required
Current New York City Retiree Health Plan: _______________________________
Individual
Family Plan
ATTACH COPY OF YOUR RETIREE HEALTH INSURANCE CARD AND THE SIGNED MEDICARE CARD FOR
YOURSELF AND YOUR ELIGIBLE DEPENDENT(S).
SPOUSE/DOMESTIC PARTNER INFORMATION:
Social Security Number: ______-_____-______
Name:
__________________________________________
Date of Birth:
Is spouse/Domestic Partner employed or retired from a NYC agency?
Yes
No
Is spouse/Domestic Partner covered on retiree’s health plan?
Yes
No
Spouse/Domestic Partner’s employment status:
Not Employed
Retired
Employed
Is spouse/Domestic Partner receiving Medicare Part B premium
reimbursement through their employer?
Yes
No
MEDICARE INFORMATION:
Medicare Claim Number
Effective Date Part A
Effective Date Part B
___________________
_________________
_________________
Social Security Number: ______-_____-______
DISABLED DEPENDENT CHILD(REN) INFORMATION:
Name:
__________________________________________
Date of Birth:
Medicare Claim#: __________________ Effective Date Part A: ________ Effective Date Part B: ________
BENEFICIARY INFORMATION (Refer to application instructions for description of beneficiary):
Name:
____________________________________
Telephone No. (
)
Address:
Apt. No.
City
State
Zip Code
AFFIRMATION:
Your signature below affirms that you have provided accurate information; that you authorize the Social Security
Administration to furnish information relative to your Medicare enrollment; that you understand that information
supplied may be used by the City to appropriately adjust your health insurance.
Signature of Retiree:
Date:
Signature of Spouse/Domestic Partner:
Date:
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