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NGSOverpaymentForm

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.

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By submitting this request you acknowledge that an immediate recoupment payment arrangement constitutes a voluntary payment and that you may be waiving the right to potential payment of interest pursuant to Section 1893(f)(2) for the overpayment(s). Note: Such interest may be payable for certain overpayments reversed at the Administrative Law Judge level or subsequent levels of appeal.*


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