Immediate Recoupment Request Form - Electronic/E-mail

Complete this online form to initiate a request for immediate recoupment of overpayment(s).

• All fields are required and the form must be completed in its entirety prior to submitting your request. 
• To avoid having to send a separate request for every overpayment letter you receive, select ‘Current and Future Overpayments’ as the Immediate Recoupment Type.
• If you do not have a current overpayment demand letter, please type “None” in the Demand Letter Number field.

Please Note: Due to PHI Internet security policy requirements, we are unable to accept Medicare numbers, SSNs, medical or confidential information.