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As used on this form you your or yours refer to the Retiree. WW-HRA-PMB-FORD-INST Jun 2008 Page 1 of 3 Ford HRA Retiree Pay Me Back Claim Form Instructions Section 1 One Time Annual Request for Social Security Administration SSA Deduct Premiums Medicare Part B Medicare Part C Medicare Advantage Medicare Part D Prescriptions Complete this section if you are requesting reimbursement for a premium that is deducted from your Social Security Check. The documentation must show at a minimum a...

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