Please allow at least 2 weeks from the Remittance Advice Mailed date before requesting a duplicate remittance advice.
Only the provider for whom the check is made payable may request a duplicate Remittance Advice (RA). No other requests will be honored.
NOTE: You can also retrieve Remittance Advices on the PROMISe™ Internet site. This feature provides you with the ability to access up to
2 years of PROMISe™ paper-based Remittance Advices. Remittance Advices are available back to March 1, 2004, or your first Remittance
Advice produced via PROMISe™.
To request a Remittance Advice, complete the form below and click on the submit button at the bottom of the page.
PLEASE ALLOW 2 WEEKS TO RECEIVE YOUR REMITTANCE ADVICE AFTER SUBMITTING THIS REQUEST
The check must be from Department 021 (located at top left corner of check). Department 021 indicates the check is from the Department of
Human Services, Office of Medical Assistance Programs.
Date: 12/16/17 (Automatically Completed)
There were errors on the form.