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.