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Get Florida Medicare Recoupment

R or other entity Please complete and forward to your Medicare contractor at the address listed below. This form, or a similar document containing the following information, should accompany every unsolicited/ voluntary refund or overpayment reporting so that receipt of the check is properly recorded and applied and/or that recovery of the overpayment is initiated. Provider/physician/supplier or other entity name Address Provider/physician/supplier NPI# Tax ID # Contact person Phone # Amount.

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