Pay Me Back Claim Form - Medicare Reimbursement Account (Mra) Page 3
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3Medicare Reimbursement Account (MRA)
Pay Me Back Claim Form
TOLL-FREE FAX:
(877) 353-9236
DO NOT USE A FAX
Or, mail to: Claims Administrator, PO Box 14053,
COVER SHEET
to ensure speedy processing.
Lexington, KY 40512
ACCOUNT HOLDER INFORMATION
Last Name
First Name
Blue Cross and Blue Shield Service Benefit Plan
Employer Name
ID Code* (Day of Birth
Birth Date
(DD) and last 2 digits of
(MM/DD)
SSN)
Email Address (complete only if new)
CERTIFICATION AND AUTHORIZATION
Signature of Account Holder X
Date
I certify that the information on this form is accurate and complete. I am requesting reimbursement for
Medicare part B premium expenses incurred by myself while I was a member of the Blue Cross and
Blue Shield Service Benefit Plan. I have not/will not seek reimbursement of this expense from any other plan
or party because I: 1) pay for the premiums through withholding, 2) have paid for the premiums out of pocket.
Use of this service indicates my acceptance of the WageWorks User Agreement at
(available upon registration; enter username and password or click on First Time User).
CLAIMS FOR OUT-OF-POCKET EXPENSES
1. One-Time Annual Request for Social Security Administration (SSA) Deducted Premiums
(Medicare Part B)
Relationship to
$
Account Holder
Service Start Date
Service End Date
Annual Out-of-Pocket
Self
(MM/DD/YY)
(MM/DD/YY)
Cost
Account Holder’s Name
2. Medicare Part B Health Plan Premiums Not Deducted from Your Social Security Check
Relationship to
$
Account Holder
Out-of-Pocket Cost
Self
Service Start Date
Service End Date
(MM/DD/YY)
(MM/DD/YY)
Account Holder’s Name
* Your ID Code is a 4-digit combination of your day of birth and the last 2 digits
$
of your SSN. For example, if you were born on the 8th day of the month and
the last 2 digits of your SSN are 12, your ID Code would be 0812.
TOTAL THIS FORM
YOU MUST ATTACH A COPY OF APPROPRIATE PROOF
WW-BCBS-FEP-MRA-RT-PMB (Dec 2017)
OF PREMIUM PAYMENT FOR EACH AMOUNT ABOVE.
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