Irrma. Student Member 3 years - Developed Country. Credit Card. To add more services to your Registration, please enter the following information:. It must be paid directly to the Federal government, not to the plans. Medicare Part B Differential Reimbursement forms: Box El Paso. Box Des Moines, IA Prescription Drug Exemption Request Form. Code the last 3 digits on the back of the credit card. Delta Dental of NY, Inc. Iconic One Theme Powered by Wordpress. Delta Dental of NY, Inc.