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Get Voluntary Refund Request Form Jurisdiction C

DME MAC Jurisdiction C Voluntary Overpayment Refund Provider/Physician/Supplier or Other Entity Information Date Please complete and forward to your Medicare contractor at the address or fax number located at the bottom of the form. This form or a similar document containing the following information should accompany every unsolicited/voluntary refund so that receipt of check is properly recorded and applied. Address City State PTAN/NPI Number Zi.

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