TIN NPI Provider Name Check Number RID MDwise Claim Date of Service Refund Amount Full or Partial If Partial Refund CPT Reason for Refund Number Refund Code(s) Mail Form and Check to: MDwise, Inc. PO Box 775166 Chicago, IL 60677-5166 *Only one TIN/NPI per form and check
TIN NPI Provider Name Check Number RID MDwise Claim Number Date of Service Refund Amount Full or Partial Refund If Partial Refund CPT Code(s) Reason for Refund Mail Form and Check to: MDwise, Inc. PO Box 775166 Chicago, IL 60677-5166 *Only one TIN/NPI per form and check