7509 Forsyth Blvd. St. Louis MO ... former employer (including but not limited to
Washington University in St. Louis), or an individual policy (not. COBRA). Proof of
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RETIREMENT MEDICAL SAVINGS ACCOUNT (RMSA) VERIFICATION OF RETIREE STATUS
Washington University in St. Louis Attn: Mary Stull Campus Box 1190 7509 Forsyth Blvd. St. Louis MO 63105
____________________________________________________ Name
_________________________________ SSN
____________________________________________________ Street Address
_________________________________ City, State, Zip Code
_________________________________ Retiree Health Plan (Company Name)
_______________________ Date of Retirement
This form is to be completed by former Washington University employees who participated in the Retirement Medical Savings Account while actively employed, separated from service from the University, have since retired and are currently enrolled in a retiree health plan. Please complete this form and return it to the address above along with proof of enrollment in a retiree health plan. Proof of enrollment includes but is not limited to a copy of your insurance card, a letter from a former employer verifying your retirement, an invoice for your retiree health insurance and/or any other proof you can provide. Enrollment in an active group employer plan through a spouse/domestic partner does not qualify. After this form has been processed, you will receive a “Claims Activation Form” from TIAA-CREF or you can print one from their website (https://www.tiaa-cref.org/public/pdf/rhp_claims_activation_form.pdf). Once that form has been submitted and processed by TIAA-CREF, you will be able to submit claims for eligible out of pocket expenses in order to be reimbursed from your RMSA. Authorization: By signing this form, I certify that I meet the definition of “eligible retiree” in the RMSA plan document located on the Washington University/Human Resources website: http://hr.wustl.edu. (A participant who attains age 55 or older, and has ceased employment at the University, and is not enrolled in an employer group health plan either as an active employee or as a dependent.) Proof of enrollment in a “retiree health plan” is included with this form. __________________________________________________ Signature
