About this form

This form may be used only to return funds distributed by the HRSA Provider Relief Fund (PRF) Uninsured Program (UIP). Do not use this form if you have a delinquent PRF/UIP debt currently in collections. To repay a delinquent debt, follow the instructions in the demand letter you received.

Accepted Payment Methods:

• Bank account (ACH)
• Debit or credit card

With an account you can:

• See the payments you made since you created an account.
• Store payment information so you don't have to re-enter it.
• Copy a form you already submitted the next time you need to make a payment.

To take advantage of these benefits, you can Sign In . If you don't have an existing account, you will have the option to create an account on the sign-in page. To continue as a guest user, click the 'Continue to the Form' button.