Provider Name

Address

Address

Dear Provider:

This letter is the SECOND NOTICE informing 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 Month(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 $ .

You must contact your Children’s Division worker within 15 days of the date of this letter to work out a repayment plan for this overpayment. If you do not respond to this second request within 15 days, we will automatically recoup the overpayment from your next payment(s).

You may request a review within 15 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 15 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