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Regence has our permission to automatically deduct the requested amount for the following claim(s):
Submission of this form serves as notification on how to proceed with your deduction request and/or Regence's recent recoupment request. Any claim(s) processed as a result of this request will be reflected in a future remittance advice. The proposed overpayment amount is based on the current claim status within our system and any adjustments could affect patient responsibility, which may include copayment, deductible amounts and coinsurance amounts.
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