2022 Medicare Part B Premium Reimbursement Appeal Form THE APPLICATION DEADLINE FOR THE 2022 PART B REIMBURSEMENT HAS PASSED.Name* First Last Email*PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth*MM slash DD slash YYYY Social Security Number*Appeal Option I haven’t received a Confirmation letter, however; I sent my application via U.S. Mail I haven’t received a Confirmation letter, however; I applied online via this website. I forgot to send in my application by the due date. I didn’t 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:* Pre-Paid Mastercard – mailed prior to December 15th, 2022 and loaded with your reimbursement Conventional Paper CheckSignature*Please enter your full name to sign this form.Consent**By checking this form and providing my signature, I attest that all information is true and accurate to the best of my knowledge.My spouse is enrolled in Medicare and wishes to apply for a reimbursement benefit. My spouse is enrolled in Medicare and wishes to apply for a reimbursement benefit.Spouse ApplicationComplete 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, 2004Spouse Name First Last Spouse PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Spouse Date of BirthMM slash DD slash YYYY Spouse Social Security NumberSpouse SignaturePlease enter your full name to sign this form.
