Overpayment Waiver Fact-Finding Statement Form
Use this form to provide the facts, dates, amounts, explanation, and supporting documents needed to review an overpayment waiver request.
Requester Information
Full Name
*
First Name
Middle Name
Last Name
Relationship to Affected Account or Case
*
Please Select
Self
Representative
Employee
Manager
Beneficiary
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Please Select
Phone
Email
Text Message
Other
Overpayment Incident Details
Date Overpayment Was Discovered
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date or Period of Overpayment
*
Source of Overpayment
*
Please Select
Payroll
Billing
Reimbursement
Invoice
Benefit
Other
Overpayment Amount
*
Brief Description of What Happened
*
Amount Status
*
Confirmed
Estimated
Not yet known
Fact-Finding Statement
Fact-Finding Statement
*
Has any repayment, adjustment, offset, or correction already occurred?
*
No action taken
Partial repayment
Fully repaid
Adjusted in a later payment
Offset applied
Unknown
Supporting Evidence and Acknowledgment
Upload payment notices
Upload a File
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Choose a file
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of
Upload supporting documents
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Submit Statement
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