Overpayment Appeal Form

Please fill out the form below to submit your appeal for overpayment from Carewell SEIU 503. Your reason(s) for appeal can either be submitted in the text box below or uploaded as an explanation letter. If you have any documentation in support of your appeal, please upload as well.

Your appeal must be submitted within 180 days of the date on the overpayment letter you received. A decision on your appeal will be made within 60 days of the Board of Trustees receiving your appeal. If the Board of Trustees needs a time extension for review, you will be notified by mail.

Name*

First NameMiddle NameLast Name

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your home address the same as your mailing address?*

YesNo

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Provider Number

Preferred phone number*

Please enter a valid phone number.

Cell phoneLandline

Email Address*

Which Carewell SEIU 503 benefit overpayment do you want to appeal?

Medicare Part B Overpayment AppealAdvance Premium Tax Credit (APTC) Overpayment AppealBenefit Convenience Card (BCC) Overpayment AppealHealthcare Cost Assistance Premium Overpayment AppealPaid Time Off (PTO) Overpayment Appeal

You have 2 options to submit your appeal letter to us:
Option 1: Use the field below to type your appeal letter to us.
Option 2: Upload your appeal letter.

Option 1: Write down your reason(s) for requesting an appeal, explaining the circumstances of your appeal in the text box.

Option 2: Upload your appeal letter and/or any supporting documents you have

Directions on how to upload files

If you DO have the files online:
1. Click on “Upload Files” on this online form
2. Select the file(s) you would like to attach/upload

If you DON’T have the files online:
1. Use a phone to take a photo of any forms and documents that you need to send to us. Make sure to take a complete picture of the form and that your name is included. We can’t read or use blurry photos.
2. Click on “Upload Files” on this online form
3. Select the file(s) you would like to attach/upload

Option 2: Upload your appeal letter and/or any supporting documents you have here.

Signature*

Today's Date*

Date