Palmetto GBA - Regional Home Health & Hospice Intermediary (RHHI) - Forms

Palmetto GBA

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Medicare Part A Overpayment Refund Form

11/19/2009

Regional Home Health and Hospice Intermediary (RHHI) Provider Outreach and Education Advisory Group (POE-AG) Membership Request Form

10/09/2009

Provider Outreach and Education Request Form - Revised September 25, 2009

10/06/2009

Electronic Funds Transfer (EFT) Registration Form (Palmetto GBA Version)

09/16/2009

Home Health and Hospice Ask-the-Contractor Teleconference (ACT) Request for Inquiry Items Form

07/16/2009

Palmetto GBA Medicare North Carolina Part A, South Carolina Part A and Regional Home Health and Hospice Intermediary (RHHI) Redetermination Request Form (Revised April 2009)

04/16/2009

Religious Non-Medical Health Care Institution (RNHCI) Form Letter

12/23/2008

Extended Repayment Plan (ERP) Form

10/31/2008

Clerical Error Reopening Request Form

05/30/2008

Hard Copy Claim Correction/Reopening Request Form (Revised May 29, 2008)

05/29/2008

Duplicate Remittance Advice Form

03/13/2008

Request for a Conditional Payment Form

12/19/2007

Palmetto GBA Temporary Change of Information Form

09/08/2005

Please Complete Your Assurance of Payment (AOP) Form

07/30/2003

Credit Balance Report Certification Page

11/02/2001

last updated on 11/19/2009

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