Self-Disclosures – Input
{"Image DocumentName": "Self-Disclosures \u2013 Input", "Image ImageDescription": "Enter basic claim information needed to identify the claim. Enter recipient\u2019s information. Enter primary payor and payment information (if applicable) Enter refund amount and reason(s) for overpayment. Click Submit to submit the report to the Supervisor for final review. As refunds are entered and saved, they appear at the bottom of the screen.", "Image XResolution": "37", "Image YResolution": "37", "Image ResolutionUnit": "Pixels/Centimeter", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}