F200021 U.S. National Health Plan (Medicare) Transmittal Form

Hidden BC

Instruction:

By checking the first box and providing the information requested below, you will be enrolled in SilverScript. Employer Prescription Drug Plan (PDP) sponsored by World Bank Group (SilverScript) for Medicare Part D prescription drug coverage. You must enroll in Medicare Part A and/or Medicare Part B in order to be enrolled in Medicare Part D.

Please check the appropriate box, complete the information below and return the Form along with a copy of your Medicare ID card showing that the effective date of your Medicare Part A and/or B coverage starts in the month of your 65th birthday as soon as possible to avoid possible disruption in coverage or late enrollment penalties.

Instructions:

Welcome to the World Bank Group HR Forms Instructions page.

This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type. Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

In case you notice any errors after printing your form, or if you've left a field blank, we recommend starting over and completing a new form. It's also important to remember that your information is not saved by the form filler and can no longer be accessed after you print it. Therefore, please be extra careful in reviewing your answers, as it is impossible to make any corrections after the form is printed.

Each form will take approximately ten minutes to complete. Please ensure you have the needed documents such as passport to extract information that may be required in some fields. Do not close the forms until they are ready for a download. Partially filled forms cannot be saved to be completed later. If you need further assistance, please contact. Thank you!

Information on Completing the Form

1. Submit with a copy of the Medicare ID card for the Retiree or the Spouse/Domestic Partner (including those in receipt of survivor spouse pensions).

2. Return this form to HR Operations. (Please select one transmittal format, and submit only once):

a. Fax +1 (202) 522-7026

b. E-mail at hroperations@worldbank.org

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

Note: This form will not be accepted without a copy of the Medicare ID card.

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 25 Apr 2023

Member Information

World Bank Group UPI*

Member Name*

Email Address*

Telephone Number*

Primary Residence

US Street address of Primary Residence (or Long-term Care Facility); (Medicare does not allow a P.O. Box)

Address*

City*

State*

Zip Code*

Enrollment Options

By checking the first box and providing the information requested above, you will be enrolled in SilverScript Employer Prescription Drug Plan (PDP) sponsored by the World Bank Group for Medicare Part D prescription drug coverage.

I choose to enroll in the SilverScript Employer PDP sponsored by the World Bank Group. I understand I will be automatically enrolled in Medicare Part D by SilverScript. I also understand that if I’m eligible for Medicare Part D and choose not to enroll in SilverScript, I will lose all prescription drug coverage from the World Bank Group. If I am the retiree, I further understand that my covered dependent(s) will also lose their coverage.

I choose NOT to enroll in the SilverScript Employer PDP sponsored by the World Bank Group prescription drug coverage. I understand that I, and my covered dependent(s), will lose the World Bank Group prescription drug coverage.

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.