2025 Medicare Part B Premium Reimbursement Appeal Form - SHN

"*" indicates required fields

THE APPLICATION DEADLINE FOR THE 2025 PART B REIMBURSEMENT HAS PASSED.

Name*

First Last

Email*

Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth*

Social Security Number*

Appeal Option

I have not received a Confirmation letter, however; I sent my application via U.S. Mail

I have not received a Confirmation letter, however; I applied online via this website.

I forgot to send in my application by the due date.

I did not receive a Medicare Part B Application to my knowledge.

Please choose one:

Select the payment option you wish to receive your Part B Reimbursement through:*

Conventional Paper Check

Signature*

Please enter your full name to sign this form.

My spouse is enrolled in Medicare and wishes to apply for a reimbursement benefit.

Spouse Application

Complete this section if you are the spouse of a living retiree.

If your spouse is enrolled in Medicare and wishes to apply for a reimbursement benefit, your spouse must complete and digitally sign the following spouse application. In order to be eligible, your date of marriage must have been before your healthcare benefits were terminated on one of the following dates. LTV Steel: March 31, 2002 Georgetown Steel: October 20, 2003 Bethlehem Steel: May 8,2003 Acme Metals: June 1, 2002 Weirton Steel: May 17, 2004

Spouse Name

First Last

Spouse Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Spouse Date of Birth

Spouse Social Security Number

Spouse Signature

Please enter your full name to sign this form.