Commercial Claim Form

Insurance Claim Form

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Insurance Claim Form

ATTN CLIENTS: This form is for Insurance recovery claims. Click here Commercial Claim Forms. Thank you.


REQUEST FOR OVERPAYMENT RECOVERY FORM

Insurance Claim Form

DATE SUBMITTED
INSURED’S NAME
DEPENDENT (if any)
POLICY NUMBER
D.O.S. (required)
CONTRACT #
S.S.# 
CLAIM #
DATE OVERPAYMENT DISCOVERED
DRAFT #
ISSUE DATE
AMOUNT OVERPAID  $
PATIENT ACCT. #
AMOUNT REFUNDED (if any) $
TOTAL OVERPAYMENT DUE  $
REASON FOR OVERPAYMENT
 

PAYEES INFORMATION

 
PAYEES NAME
PAYEES ADDRESS
PAYEES TELEPHONE NUMBER
REQUESTOR
COMPANY NAME
COMPANY ADDRESS
COMPANY TELEPHONE
E-MAIL ADDRESS


HARRIS, KLEIN ASSOCIATES, INC.
224 CREEKSTONE RIDGE WOODSTOCK, GA 30188
OFFICE: 770-591-7499 - 1-800-440-1452 - FAX: 770-924-2289 - 1-800-692-1601