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Of the demand letter 3. Select the option you prefer for this fax 4. Sign and provide contact name and phone number 5. If you are a PA, NJ, MD, DC, or DE provider, fax to: (717) 728-8722 If you are an AR, CO, LA, MS, NM, OK, or TX provider, fax to: (717) 728-8728 This form should be faxed to Novitas Solutions Part B no later than the 16th day from the date of your initial demand letter. NOTE: Providers who request immediate recoupment must realize it is considered a voluntary repayment. Require.

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