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.

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