Medicare Refund Form
Provider/Facility Information
Name of Provider/Facility
Provider/Facility Identification Number
Contact Person
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Information (if applicable)
Patient Name
First Name
Last Name
Medicare Beneficiary Number
Date of Service
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Refund Request
Billing Details
Original Claim Number
Date of Original Submission
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Refund Request (e.g., overpayment, billing error)
Total Amount to be Refunded $
Method of Refund
Check
Electronic transfer
Other
Documentation (attach relevant documents, if necessary)
Browse Files
Drag and drop files here
Choose a file
Copy of the original Medicare claim, Supporting documentation highlighting the error, etc.
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of
Submit
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