Medicare Part B Annual Premium Reimbursement Request - un.org 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, clearly print your name, index number, mailing address, retiree number, personal email address, and telephone number. Ensure all information is accurate for processing.
3. Move to Section 2 to claim your Part B premiums. Enter the name of the participant, their relationship to you, Medicare ID number, coverage period (from and to), and the monthly premium paid. Remember to attach proof of payment like Form CMS-500.
4. If this is your first reimbursement claim, complete Section 3 with your bank information. Provide the bank name, account number, and routing or ABA #. If claiming for a spouse, ensure you use the primary subscriber’s account details.
5. Finally, sign and date the form at the bottom to confirm your understanding of ongoing payments for Medicare Part B coverage.

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