Complete a Voluntary Refund

A voluntary refund is when you have self-identified you have been overpaid and you need to refund the excess funds to Medicare. All checks are made payable to National Government Services.

Whenever possible the refund to Medicare should be completed through the claims system by initiating an adjustment. Customer Care should be contacted if you are unsure whether or not you are able to initiate the claim adjustment as well as if you have questions about how to adjust a claim. If initiating the adjustment is not possible, the voluntary refund form should be completed.

You have two options:

1. Submit a check with the voluntary refund form. When the claim(s) is adjusted, Medicare will apply the monies to the overpayment.
2. Submit the voluntary refund form without a check and when the claim(s) is adjusted, Medicare will take back the overpayments through the offset process.

Completing the Voluntary Refund Form

1. Complete the form in its entirety as missing information will delay processing.
2. Be sure the form is mailed to the appropriate address listed at the bottom of the form.
3. Include any additional documentation that would enable processing of the request.

Revised 8/24/2021