1. Read the letter thoroughly to understand the context. Please download the form, complete each field and print.Include the form with your refund so we can properly apply the refund and record the receipt. We have identified the following overpayment and are in good faith voluntarily refunding all monies collected in error. If you are unable to submit this amount, please contact DHS within ten calendar days from the date of this letter at. This form allows patients to request a refund for services provided. The salary overpayment resulted because .