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Uben 121 2026
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- Click ‘Get Form’ to open the uben 121 in the editor.
- Begin by entering the Retiree Name and Social Security Number (SSN) clearly. This information is crucial for processing your enrollment.
- Fill in the Requested Effective Date, ensuring it is a future date. Remember, you can submit this form up to 90 days before that date.
- If you are not the retiree, provide your name and SSN along with your Date of Birth.
- Complete the Permanent Residence Address section accurately, as P.O. Boxes are not accepted. If applicable, include your Mailing Address if it differs from your residence.
- Indicate if you have End-Stage Renal Disease (ESRD) and provide the diagnosis date if applicable.
- Enter all details from your Medicare card, including the Medicare Number. You may also attach a copy of your card for verification.
- Finally, ensure that you sign and date the form at the designated area. If someone else is signing on your behalf, their details must be filled out as well.
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