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SAMPLE
MEDICARE PART B PREMIUM REIMBURSEMENT
QUARTERLY PAYMENT REQUEST
For the CALENDAR Quarter Ending 09 / 30 / 2021
FC 1646 (101918)
Side 1 of 2Retiree Information (Please print clearly)
Retiree
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02
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What is how to pay part?
How to pay part is a section of a form or document that specifies the method or process for making payments.
Who is required to file how to pay part?
Any individual or entity who is responsible for making payments as specified in the document.
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The purpose of how to pay part is to ensure that payments are made correctly and in a timely manner.
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The information that must be reported on how to pay part typically includes payment amounts, due dates, payment methods, and relevant account details.
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