Refund Request Form
Manual Refund Request Form
Date: _____________________________________
Office Location: _____________________________________
Patient Number: _____________________________________
Patient’s Name: _____________________________________
Check Payable To: _____________________________________
Street Address: _____________________________________
City, State, Zip: _____________________________________
Amount of Refund: _____________________________________
Reason for Refund: _____________________________________
_____________________________________
_____________________________________
Processed By: ____________________________________________
Authorizing Signature: _____________________________________
Original copy should be faxed to (972)616-9986, Attn: Accounts Payable Department. Copy should be filed in patient’s chart and notation of refund made on patient’s ledger card.
[pic]
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- tax hardship refund request form
- tax offset refund request form
- annual credit report request form pdf
- dhs hearing request form michigan
- refund request aspen dental complaints
- credit report request form pdf
- medical records request form pdf
- refund request form
- equifax annual credit report request form pdf
- idr plan request form 2019
- nycha transfer request form pdf
- mandatory forbearance request form 2019