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Refund request form
This form is to be used to request a deduction on a future remittance advice (voucher) in response to a recent recoupment request from Regence, or as a result of an overpayment discovered by your internal claims review process. Please use the comment section for additional information. Please note: If you have received a mailed refund request from Regence it will automatically be deducted from the future voucher.

Regence has our permission to automatically deduct the requested amount for the following claim(s):

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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.