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1199SEIU National Benefit Fund fax number
(646) 473-7089
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Retiree Health Benefits – Medicare Part B Premium Reimbursement
Used for: Filing Medicare Part B premium reimbursement claims using the Medicare Part B Reimbursement Claim form; submit claims for eligible years (last two years) by mail or fax; include supporting documents such as SSA award letter and proof of Medicare Part B premium payment.
Fax destination details
- Department
- Retiree Health Benefits – Medicare Part B Premium Reimbursement
- Purpose
- Filing Medicare Part B premium reimbursement claims using the Medicare Part B Reimbursement Claim form; submit claims for eligible years (last two years) by mail or fax; include supporting documents such as SSA award letter and proof of Medicare Part B premium payment.
- Form
- Medicare Part B Reimbursement Claim — Statement of Claim for Medicare Part B Premium Reimbursement
- Address
- PO Box 2661, New York, NY 10108-2661
- Voice phone
- (646) 473-8666
- Website
- Visit organization website
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Complete the form with member and spouse details, select claim year and months, attach required documents (SSA award letter, Medicare card, proof of premium payment), sign and date, then submit by mail, fax, or email as directed.
Official form instructions are published as a downloadable file on the organization's website.
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