Refunds/Overpayments Forms - JA DME
Refunds/Overpayments Forms
- Accelerated and Advance Payment Form [PDF]
- CAAP Debt Dispute Form [PDF]
- CMS 379
- Financial Statement of Debtor
- ERS Amortization Schedule [Excel]
- Extended Repayment Schedule (ERS) Request [PDF]
- Immediate Recoupment/Offset [PDF] - When requesting immediate recoupment before automatic offset
- MSP Overpayment Refund Form [PDF] - Refund related to Medicare Secondary Payer (MSP) claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form for multiple requests
- Non-MSP Voluntary Refund Checks Form [PDF] - Submit a refund not related to MSP - use when enclosing a check
- Non-MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form for multiple requests
- Instructions Non-MSP Overpayment Refund Request - to submit an overpayment request not related to MSP - use when not enclosing a check
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