Home
Forms Library
Overpayment Request Form

Overpayment Request Form 2025

Overpayment Request Form Preview on Page 1

Show details

4.3 out of 5

58 votes

The document is an Overpayment Adjustment Request Form for Anthem Blue Cross and Blue Shield members, detailing the process for providers to request refunds for overpayments. It includes instructions on where to send the form based on member type (FEP or regular members), fields to be completed by the provider, options for recoupment or refund, and reasons for requesting a refund.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to edit Overpayment Request Form in PDF format online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Working on documents with our extensive and user-friendly PDF editor is simple. Make the steps below to fill out Overpayment Request Form online quickly and easily:

Sign in to your account. Log in with your email and password or register a free account to test the product before upgrading the subscription.
Upload a document. Drag and drop the file from your device or add it from other services, like Google Drive, OneDrive, Dropbox, or an external link.
Edit Overpayment Request Form. Effortlessly add and highlight text, insert pictures, checkmarks, and icons, drop new fillable fields, and rearrange or remove pages from your document.
Get the Overpayment Request Form accomplished. Download your adjusted document, export it to the cloud, print it from the editor, or share it with others via a Shareable link or as an email attachment.

Make the most of DocHub, one of the most easy-to-use editors to quickly handle your paperwork online!

See more Overpayment Request Form versions

We've got more versions of the Overpayment Request Form form. Select the right Overpayment Request Form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (121 Votes)
2012	4.3 Satisfied (58 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a SSA 634 form?

The purpose of the SSA-634 is to gather information to assist technicians with determining if they can approve a change in an individuals repayment rate if the individual cannot pay their entire debt within 60 months, or if the current recovery rate will not allow the individual to afford their ordinary and necessary

Does Social Security ever forgive overpayments?

If you got a letter in the mail that says you were overpaid and need to pay us back, you can request a waiver. Ask us to waive repayment if you cant afford it and feel the error wasnt your fault, or if you believe the overpayment is unfair for another reason. We may ask to see details about your income and expenses.

How do you fight overpayments?

If you do not think you owe the money, you can ask SSA to reconsider the overpayment by filing a Request for Reconsideration Form (SSA561-U2). You can also call your local Social Security office and ask them to take your appeal over the telephone.

What is an overpayment request?

A benefit overpayment is when you collect unemployment, disability, or Paid Family Leave (PFL) benefits you are not eligible to receive. It is important to repay overpayments to avoid collection and legal action.

How do you resolve overpayments?

How To Correct a Payroll Overpayment Step 1: Gather Data. Before taking any action to correct overpaid wages, youll need to get your facts straight. Step 2: Check State Laws and Company Policies. Step 3: Notify the Employee. Step 4: Discuss Repayment Options with the Employee. Step 5: Adjust your payroll.

What is a SSA 3105 form?

Form SSA-3105 is used to request to be selected as a payee for someone who receives Social Security or SSI benefits but cant manage or direct the management of their advantage. Originally published by: ssa.gov.

How can I get out of paying back an overpayment of Social Security?

If you believe that you may have been overpaid, but feel that it was not your fault and you cannot afford to pay us back, you may ask for: A waiver of the overpayment. And complete form SSA 632 (Request for Waiver of Overpayment Recovery).

Can I dispute an overpayment?

If you do not agree that you have been overpaid, or if you believe the amount is incorrect, you can appeal by filing Form SSA-561, Request for Reconsideration. You should explain why you think you have not been overpaid or why you think the amount is not correct.

Overpayment Request Form 2025

Here's how it works

How to edit Overpayment Request Form in PDF format online