Download and complete the Medicare Compensation Recovery Notice of reimbursement arrangement form.
This notice should be sent to us within 28 days.
You can fill in this form and sign it digitally. You can do this by downloading it on a computer or a device that has Adobe Acrobat Reader. If you don’t have Adobe Acrobat Reader you can print it and sign it by hand.
This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.
If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use business online services or contact us. We can help you access, complete and submit them.