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Get and Sign Medicare Immediate Recoupment Form 2015-2022

Get and Sign Medicare Immediate Recoupment Form 2015-2022

Use a medicare imediate recupment 2015 template to make your document workflow more streamlined.

Number Missouri Nebraska Letter Date Provider Name: Provider PTAN: Provider NPI Number: Last Five Digits of Provider’s TIN: Contact Name: Contact Phone Number: Extension: (Optional) I would like all future overpayments set up for immediate recoupment (Optional) I would like to discontinue immediate recoupment of all future overpayments I understand that by submitting this request for immediate recoupment, I am waiving potential receipt of interest payment pursuant to Section 1893(f)(2) for...
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