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Refund Request (Account Discrepancy Form)

Requests for credits should be made within 60 days of the query submission. If you suspect that your bill is incorrect, or you need more information about a transaction, you should complete this form. Requests are usually responded to within 5-7 business days of receipt.

Note: Fields with an asterisk (*) are required in order to ensure an accurate response; the information will not be used for any other purpose.

OMB # 0915-0126 expiration date 03/31/21

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0126. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.