Our document template is designed to make the process of writing an "Inform a Customer of an Overpayment" letter quick, easy, and stress-free. A new electronic Payment Adjustment Request form for fee-for-service Medicaid claims is now available for issues regarding overpayment and credit balance.The salary overpayment resulted because . 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.