F00032 Retiree MIP Medicare Reimbursements

Purpose of this Form: F00032 Retiree MIP Medicare Reimbursements

1.  Use this form to claim reimbursement of the Medicare Part B standard premium and Income-Related Monthly Adjustment Amounts (IRMAA) Parts B and D, if applicable.

2.  Along with this form, you must attach or include copies of all letters you received from the Social Security Administration (SSA) that show the Medicare Part B premium and IRMAA Parts B and D (as applicable) you owe for the period for which reimbursement is claimed. Click here to view an example of a Social Security Administration Medicare Notice.

Information on Completing the Form

Please note that you can complete this form online and save it to your computer. Alternatively, you can print a blank form from the 1818 website and complete it by hand. If you choose to complete this form online and save it to your computer, please follow the instructions below:

1.  Do it in one go. Partially filled-out forms cannot be saved to be completed later. Please complete it at once. It takes approximately 5 minutes to complete the form.

2.  Signing the form is the last step before saving it as a PDF document on your computer or printing it out. 

3.  There are two options for signing the form online: Under the signature block you will see a keyboard icon or pen/brush icon. If you choose the keyboard icon, you can type your name. If you choose the pen/brush icon you can draw your name. Either option is acceptable.  

4.  The form should be sent back to HR Operations. You can send or submit the form along with the supporting documents via:

a. Fax: +1 (202) 522-7026 

b. E-mail: hroperations@worldbank.org

c. Mail to or in person: HR Operations, World Bank MSN G2-202, P.O. Box 1420, Landover, MD 20785, USA 

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 15 Dec 2023

SECTION 1: Retiree's Information

World Bank Group UPI*

First Name*

Last Name*

E-Mail Address*

Select member*

SECTION 2: Reimbursement Information

Provide the following information for each person included in this claim, retiree and/or spouse/domestic partner.

First Name:*

Last Name:*

Relationship*

I confirm I am attaching the following supporting document(s)*

This claim corresponds to the period

From:*

To:*

SECTION 3: Certification and Signature

I certify that the statements made by me on this form are complete and true to the best of my knowledge and belief, that I have paid or expect to pay all Medicare premiums, and that any misrepresentation may result in disciplinary action under  Staff Rule 3.00. I further certify that I will promptly inform HR Operations if there is any change in the premiums I owe in the course of the year so that reimbursement amounts can be adjusted accordingly.

Retiree's signature:*

Date signed:*

Before saving the form as a PDF, please ensure that all details are correct. If you notice any mistakes, please click the back button and correct them.

Example of a Social Security Administration Annual Medicare Notice. 

This is an example for a case where the Retiree does not have Social Security benefits.

Note: the letter continues for several pages, but the application requires only the part up to and including the IRMAA amount you owe (outlined in red above).