Palmetto GBA
Close Window [x]
  • Entire Site
  • J1 WPS Transition
  • J1 Part A
  • J1 Part B
  • LA & MS Part A EDI
  • NSC
  • Ohio Part B
  • Part A Intermediary
  • Railroad
  • RHHI
  • SC Part B
  • WV Part B
permaLink

South Carolina Part B Carrier
Financial Statement of Debtor Form: CMS-379

Sole proprietors must use the Financial Statement of Debtor form to request an extended repayment plan (ERP) for an overpayment debt. This form must be completed and mailed with an ERP form (also available on this Web site). To access the form, go to: www.cms.hhs.gov/cmsforms/downloads/cms379.pdf.

 

last updated on 11/07/2008