Fillable Standard Provider Refund Form printable pdf download

Standard Provider Refund Form

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Standard Provider Refund Form

Please use this form to submit your refund should you receive an

overpayment from ConnectiCare.

Send to:

ConnectiCare VIP Claims Refund

Courier Delivery Address:

Bank of America Merrill Lynch

P.O. Box 416947

Lockbox Services

Boston, MA 02241-6947

Lockbox 416947, Ma5-527-02-07

2 Morrisey Boulevard

Dorchester, MA 02125

Provider name: _____________________________________________ Date: ___________________________

Provider ConnectiCare ID: ____________________________________

Address: ___________________________________________________

____________________________________________________

Authorized signature:_________________________________________ Date: ___________________________

Please check one of the following:

Please deduct this overpayment from future remittance.

I have attached the check to be voided.

I have attached a personal check to refund the overpayment.

Check No.: ___________________

Amount: _____________________

Amount: ____________________

Patient’s name: ____________________________ ConnectiCare Member ID: _________________________

Claim number: ____________________________ Date(s)of service: __________________________________

Procedure/service: __________________________ Total charge: _____________________________________

Reason for refund (check one)

Charges billed in error (explain)__________________________________________________________

___________________________________________________________________________________

Duplicate payment

Not our patient

No fault insurance

Paid by other insurance

Workers’ compensation

Other (explain)_______________________________________________________________________

___________________________________________________________________________________

Medicare PPM/3.12

Standard Provider Refund Form

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