Forms

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 COVID-19 Accelerated and Advance Payment CAAP Debt Dispute Request
Jurisdiction 6 Medicare Part A MSP Overpayment Request Form
Jurisdiction 6 Medicare Part A Overpayment Request Form
Jurisdiction K COVID-19 Accelerated and Advance Payment CAAP Debt Dispute Request
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