Get Jf Medicare Part B Provider Request For Immediate Recoupment This Form Is Used When Providers Want

This guide provides step-by-step instructions on how to accurately complete the JF Medicare Part B Provider Request For Immediate Recoupment form. This process is crucial for providers seeking timely recoupment of their Medicare payments against outstanding debts.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the required fields: Enter your provider name in the designated space.
3. Provide your Provider PTAN and/or NPI in the appropriate field to identify your Medicare contract.
4. Complete the provider contact information, ensuring you provide a reliable phone number for any follow-up.
5. If applicable, add your fax number where you can receive correspondence.
6. Specify your state according to your business location.
7. Enter your letter number, which helps identify the demand letter associated with your request.
8. Sign the form as the provider or CFO, ensuring authorization for the request.
9. Select the type of recoupment requested: check the box for either a one-time request, specific overpayment, or to discontinue recoupment of future overpayments.
10. Once completed, send this form along with the demand letter via fax to the number provided (701-277-7874) or mail it to the appropriate address for your state.
11. After carefully reviewing all entries, save, download, or print the completed form for your records.

Start filling out the JF Medicare Part B Provider Request for Immediate Recoupment form online now!