Provider Name:
Provider Number:
Demand Letter Number(s):
State Services were Rendered: (please choose state)
Line of Business (please choose one):
Select one of the following options for immediate recoupment:
A one time request for all invoices included in the current overpayment demand letter(s) listed above and all
future overpayments.
A request for all invoices in only the current overpayment demand(s) letter listed above
A request to discontinue participation in the immediate recoupment/offset process for all future requests
To Request Immediate Recoupment/Offset:
1. Fill out the information above
2. Attachacopyofthefirstpageofthedemandletter
3. Select the option you prefer for this fax
4. Sign and provide contact name and phone number (see below)
5. Fax to the below fax numbers:
(904) 361-0359 – Part A providers
(904) 361-0444 – Part B providers
NOTE: Providers who request immediate recoupment/offset must realize it is considered a voluntary repayment.
Signature (Provider, Administrator, or CFO): _____________________________________________________
Contact Name: _____________________________________________________________________________
Contact Phone Number: ______________________________________________________________________
Incomplete forms may delay processing which can cause interest to accrue on the debt. If there is a remaining principal
balance after the initial immediate recoupment request has been processed, attempts to recoup immediately will continue.
Interest will accrue if a principal balance remains after 30 days from the date of the demand letter and further collection
activities will be pursued after 41 days from the date of the demand letter.
By signing the form you are acknowledging that you understand that going through the immediate recoupment/offset
process is considered to be a payment arrangement that constitutes a voluntary payment and will not be subject to 935(f)
(2) interest pursuant to 1893(f)(2). The exception to this is when your appeal at the Administrative Law Judge (ALJ)
prevails, any money recouped/offset 30 calendar days after the reconsideration decision will be subject to 935 interest.
53001 (12-19)
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