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IRMAA reimbursement for both the enrollee and dependent will be issued to the enrollee only. In order for the Employee Benefits Division to speak with a dependent regarding the IRMAA application, the enrollee must complete and sign the NYSHIP Authorization for Release of Protected Health Information Form (EBD -543).
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October 2017 Health Insurance Choices for 2018
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HEALTH INSURANCE CLAIM FORM New York State …
www.cs.ny.gov9d. Other insured’s insurance plan or program name (C): Enter the other insured person’s insurance company or program name. 10a. Select whether the member’s condition is related to employment (R). 10b. Select whether the member’s condition is related to an auto accident and enter the state in which the accident occurred (R). 10c.
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2019 Medicare Part B Premium Reimbursement
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