Forms - NGSMEDICARE

Overpayments

Applying for an Extended Repayment Schedule

Financial Contact Information Form

Immediate Recoupment Request Form – Electronic/E-mail

J6 Applying for an Extended Repayment Schedule

J6 Medicare Secondary Payer Overpayment Request Form

J6 Medicare Secondary Payer Part B Carrier Voluntary Refund Form

J6 Overpayment Recovery Unit Part B Carrier Voluntary Refund Form

J6 Part A Immediate Recoupment Request Form

J6 Part A Overpayment Recovery Unit Voluntary Refund Form

J6 Part B Applying for an Extended Repayment Schedule

J6 Part B Immediate Recoupment Request Form

JK Applying for an Extended Repayment Schedule

JK Extended Repayment Plan Request Form

JK Medicare Secondary Payer Part B Carrier Voluntary Refund Form

JK Overpayment Recovery Unit Part B Carrier Voluntary Refund Form

JK Part A Immediate Recoupment Request Form

JK Part A Overpayment Recovery Unit Voluntary Refund Form

JK Part B Immediate Recoupment Request Form

JK Part B Medicare Secondary Payer Overpayment Request Form

Jurisdiction 6 Medicare Part A MSP Overpayment Request Form

Jurisdiction 6 Medicare Part A Overpayment Request Form

Jurisdiction K Medicare Part A MSP Overpayment Request Form

Jurisdiction K Medicare Part A Overpayment Request Form

Medicare Credit Balance Report (CMS-838) Excel Spreadsheet

Medicare Credit Balance Report Form and Instructions (CMS-838)

Overpayment Recovery Unit FQHC Voluntary Refund Form