Medicare Secondary Payer (MSP) Forms
- MSP Overpayment Refund Form [PDF] - Refund related to MSP claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form
- Medicare Secondary Payer [PDF]
- Medicare Secondary Payer Questionnaire [PDF] - Use to facilitate identification and proper billing of MSP cases. Beneficiary or registration personnel may complete
Due to varying Internet Browsers and versions of Adobe, users may receive the error message, "Adobe PDF Document. There is a problem with Adobe Acrobat/Reader. If it is running, exit, and try again. (0:104)"
If this occurs, close the error message and use the browser "refresh" button, or press the F5 key, to reload the PDF.
Interactive Form Tips
Select "Highlight fields" and/or "Highlight required fields" to ensure all form fields are completed.
To view field instructions (including CMS supplied instructions, when provided), hover over desired field.
Blank and completed forms may be saved to a user's computer. Right-click PDF hyperlink and select "Save as."
Electronic completion minimizes possibility of illegible handwritten forms.
Last Updated Oct 25, 2018