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Fillable EBD-2956 IRMAA Form - Department of Civil Service - cs ny

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2011 MEDICARE PART B INCOME RELATED ADJUSTMENT AMOUNT (IRMAA) REIMBURSEMENT APPLICATION Please complete this form ONLY if you and/or your dependent is subject to the 2011 Medicare Part B Income Related Adjustment Amount (IRMAA). Submit this completed form and required documentation to: NYS Department of Civil Service Employee Benefits Division Attn: IRMAA Accounting Alfred E. Smith State Office Building Albany, NY...
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