Provider Name

Address

Address

Dear Provider:

This letter is to notify you there has been an overpayment in the amount of $ , which was made to you or your facility on behalf of, Child's Name for Service Date(s). The overpaid service was Service Code Description.

Your contract with the Children’s Division indicates that your payment for this service should have been $ .

Please contact your Children’s Division worker within 30 days of the date of this letter to work out a repayment plan for this overpayment.

You may request a review within 30 days of the date of this letter, if you do not agree an overpayment has occurred. Your written request for a hearing must be sent to your Children’s Division worker within 30 days of the date of this letter.

Questions about this letter can also be directed to your Children’s Division worker.

Sincerely,

Circuit Manager or Designee

County Office

Children’s Division