MBI Form - Benefit Fund of the IBEW Local 697

MBI (MEDICARE BENEFICIARY IDENTIFIER) FORM

Please complete in its entirety and return to the Fund office.

Name*
First Name Last Name
Address*
Street Address Suite / APT # City State / Province / Region ZIP / Postal Code
MBI #*
LOCAL 697 MEDICAL ID #*
Phone #*
Email Address*
Email
This field is for validation purposes and should be left unchanged.

Fill out the form in its entirety
If you are unclear as to what a Medicare Beneficiary Identifier (MBI) is, it is the alpha numeric number that is listed on your red, white and blue Medicare card under the section on that card titled “Medicare Number.” It is that alpha numeric number that you must place within the space to the right of the MBI# on the MBI form
Do not forget to include your medical identification number. This can be found on your MagnaCare ID card.
If you do not have an email address, then write either “Not Applicable” or N/A within that spot.
Moreover, if you have a relative who assists you in these types of matters or if you wish to place them as a contact person, feel free to list their name and phone number and/or email address in those fields on the form. If you need more space, then place that information on a separate sheet of paper and submit that along with your properly completed form.
Please include a copy of your Medicare Health Insurance card along with the properly completed Medicare Beneficiary Identifier Form to the Fund Office. This is greatly appreciated as sometimes a letter, or a number is misinterpreted and having a copy of that card eliminates any confusion.
Mail your fully completed form and copy of your red, white and blue Medicare Health Insurance card back to: