Refunds/Overpayments Forms - JA DME
- Accelerated and Advance Payment Form [PDF]
- CMS 379 - Financial Statement of Debtor
- Extended Repayment Schedule (ERS) Request [PDF]
- Immediate Recoupment/Offset [PDF]
- MSP Overpayment Refund Form [PDF] - Refund related to Medicare Secondary Payer (MSP) claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form
- Non-MSP Overpayment Refund Form [PDF] - Refund not related to MSP claim
- Non-MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form
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Last Updated Thu, 25 Oct 2018 12:52:21 +0000