Tiaa-Cref Medicare-Eligible Retirees Application For Medicare Part B Premium Reimbursement Form

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UBO USE ONLY
RET/TERM Date: _____________________
EE Med Part B: _______________________
SP/DP Med Part B: ____________________
st
1
Payment Year: ______________________
PYC’s:_______________________________
TIAA-CREF MEDICARE-ELIGIBLE RETIREES
APPLICATION FOR MEDICARE PART B PREMIUM REIMBURSEMENT
RETIREE INFORMATION:
Social Security Number: _____-_____-_____
Name:
___________________________________________
Date of Birth:
Address:
No. and Street
Apt. No.
(
)
City
State
Zip Code
Telephone No.
Email Address:
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 deductions being withheld from your pension check for retiree health insurance?
Yes
No
No Premium Required
Current New York City Retiree Health Plan: _______________________________ Individual or Family Plan (circle one)
_______
PLEASE ATTACH A COPY OF YOUR RETIREE HEALTH INSURANCE CARD AND THE 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 (Complete for retiree and/or spouse/domestic partner):
Effective Date
Effective Date
Hospital Insurance
Medical Insurance
Name
Medicare Claim Number
(Part A)
(Part B)
Retiree
Spouse/Domestic Partner
DISABLED DEPENDENT CHILD(REN) INFORMATION:
Date
Effective Date
Effective Date
of
Hospital Insurance
Medical Insurance
Name
Birth
Sex
Medicare Claim Number
(Part A)
(Part B)
BENEFICIARY INFORMATION (Refer to application instructions for description of beneficiary):
Name:
____________________________________________________
Address:
No. and Street
Apt. No.
(
)
City
State
Zip Code
Telephone No.
AFFIRMATION:
Your signature below affirms that you have not knowingly made a false statement; 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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