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57 11/2005
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Refund Memorandum
Mail to: Cash Receipts Department
Blue Cross Blue Shield Healthcare Plan
of Georgia
P.O. Box 4445
Date:
Atlanta, GA 30302
BlueChoice PPO
Patient’s Name Member’s Name
Primary Contract Number Primary Group Number
Secondary Contract Number Secondary Group Number
____/____/____ ____/____/____
Claim Number Admission Date Discharge Date
Please indicate below why this refund is being sent back to us.
Our records indicate that this patient was not treated at our facility during the time these services were
rendered.
This payment has previously been made by Blue Cross Blue Shield of Georgia for the same dates of
service and amount:
Initial payment made on ____/____/____ in the amount of $______________.
Final payment made on ____/____/____ in the amount of $______________.
Blue Cross Blue Shield of Georgia is the secondary (COB) insurance carrier.
_________________
is the primary carrier and they made payment on
____/____/____ in the amount of $_______________
I am refunding: Total amount paid by Blue Cross Blue Shield of Georgia
Difference between primary and secondary payments.
$______________
Amount of Refund
Other, Please Explain:
Provider Representative: