Internal Refund Request Template

Copy and Paste the following template below onto a word Doc and fill out accordingly.

Capital Pediatric Cardiology Refund Request Form

Date: Refund Total:
Guarantor ID: Guarantor Name:
Invoice/Account# Payment Type:
Payment Date: Claim#
Date of service: Place of service:

Reason for Refund:



Supporting Documents: (original EOB original payment required)

Pay to:


Biller's Initials:

Approval date:

Refund Date: