1199 medicare part b reimbursement form-2025

1. Click ‘Get Form’ to open the 1199 Medicare Part B reimbursement form in our platform.
2. Begin by entering the member's full name and ID number in the designated fields. Ensure that you print clearly in blue or black ink.
3. Fill in the member's date of birth and primary telephone number, followed by their address, city, state, and zip code. Indicate if this is a new address.
4. Next, provide the spouse's date of birth and primary telephone number, along with their address details. Again, indicate if this is a new address.
5. In the MEMBER'S CLAIM section, enter the claim year and check the boxes for each month claimed for reimbursement. Repeat this process for the SPOUSE'S CLAIM section.
6. Finally, ensure that both members sign and date the form at the bottom to validate your claims before submission.

Start using our platform today to easily complete your 1199 Medicare Part B reimbursement form for free!