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Refund Form

Refund Form

Use a Refund Form 0 template to make your document workflow more streamlined.

500 1st Avenue Pittsburgh PA 15219. PLEASE COMPLETE Date Group Name Group Number Address Phone Number Practitioner Name Individual Provider Number Vendor Name Tax Identification Number Contact Person at Provider s Office E-mail Address Member/Claim Information Name Gateway ID DOS Claim Number Refund Amount Reason for Refund Payment of Outstanding Credit Balance AR Medicare Auto-Insurance Identified Medicaid Member Only Unable to Identify Patient Comment Four Gateway Center 444 Liberty Avenue...
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