Forms

Medicare Part B Update! Subscription, Physicians and Nonphysician Practitioner Fee Schedule

The purpose of this authorization is to permit Medicare to release to a third party, specific Medicare records and or claim information.

Use this information to establish Electronic Funds Transfer (EFT).

Please use the Redetermination Request Form for first-level appeal requests.

Provider must select options. If none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the bottom of the form.

This form is to be used for 2nd level appeals only. Please use the Redetermination Request Form for 1st level appeal request.

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