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FN-JM-B-2020 Revised 3/2017 Please send this form and all additional documentation to Palmetto GBA LLC Finance Accounting P. Please enclose the check made payable to Palmetto GBA or Medicare otherwise the check cannot be accepted for deposit. PLEASE DO NOT USE STAPLES FOR ANY DOCUMENTATION Voluntary Refund Overpayment Check Enclosed ALL elds are REQUIRED. For your convenience submit this form and your payment electronically via the eServices portal located at www. PalmettoGBA. com/eServices...

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c blueslate clients palmetto is a specific form or document used by a company to report client information.

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