Notice of Overpayment
and Planned Action for
Provider Overpayments / Date of notice:
Provider name:
DPU provider number:

We found that from // to //the Department of Human Services (DHS)paid you $ more than you should have been paid.

The reason for this overpayment is: .

This overpayment is Agency caused Provider caused

This overpayment is related to the following DHS case:
Case number: Case name: Worker ID: Branch:

You must pay back the money you were overpaideven if it was not your fault. You have to pay it back even if you didn’t know you were getting too much money. If you have questions about this overpayment, contact the Overpayment Writing Unit,childcare provider overpayment team,at:503-373-1872 (Salem area), 1-877-888-3578 (toll free)or by fax
503-378-3872.

You may also contact us in writing at the following address:

Overpayment Writing Unit

P.O. Box 14150

Salem, Oregon 97309-0850

DHS may increase the amount of this overpayment if we learn of additional payments that you were not eligible to receive. Oregon Administrative Rules:

461-155-0150, 461-165-0160, 461-165-0180, 461-165-0430, 461-195-0501,

461-195-0541, 461-195-0521, 461-195-0551, 461-195-0621

Repayment methods

  1. Oregon law requires you to repay this money to DHS. The law allows DHS to take court action to collect the overpayment. The law also allows DHS to collect money from other state agencies that owe you money. For example, we can take Oregon tax refunds. We credit amounts we collect minus collection fees or costs charged to DHS in the collection process.
  2. Special notice for childcare providers:

If you are a current childcare provider for DHS, when you bill DHS, we withhold the amount of overpayment from the amount we would have paid you for services. We keep all or part of your current and future payments until the overpayment is paid. This is in addition to number 1 above.

If your household income is low and withholding causes a financial burden, we may consider a repayment plan.You must contact the Direct Pay Unit, at1-800-699-9074(toll free) or 503-378-5500(Salem area) within 45 days from the date of this notice to request a repayment plan.

  1. If you are not currently a childcare provider with DHS, you need to pay the overpayment within 60 days. If you do not, you will not be eligible for payments from DHS until you repay the full overpayment.
  2. To repay this amount, please send your check or money order along with this
    notice to:

DHS– Accounts Receivable and Receipting Units

OFS RSTARS Receivables

P.O. Box 4325

Portland, OR97208-9992

Questions call: 503-947-5126

Note: Be sure to include a copy of this notice with your payment or write your provider number on your check. Your provider number can be found at the top of the first page of this notice.

If you do not agree

You have the right to ask for a hearing if you do not agree with this overpayment. At the hearing, you can explain why you do not agree with the overpayment. You can also have people testify for you. You can have a lawyer or someone else help you. We cannot pay the costs of witnesses or a lawyer. You may call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 1-800-520-5292 for advice and possible representation. You may also be able to get free legal services through your local bar association. The laws about your hearing rights and the hearing process are at OAR 137-003-0501 to 0700, 461-025-0300 to 0375, ORS 183.411 to 183.470 and ORS 411.703.

If you want a hearing, you must ask for one within 45 days from the date of this notice. You have the right to ask for a delay paying DHS back until a hearing decision is made. Your hearing request must be in writing and may be submitted on a DHSAdministrative Hearing Request Form (DHS 443). The form is available at your local DHS office. DHS staff can help you fill out the form.There are times when you do not have a right to a hearing. You do not have a right to a hearing if:

  • You already had a hearing on the same issue.
  • You did not ask for a hearing within 45 days from the date of the notice.
  • You signed legal papers admitting you received this overpayment.
  • A court has decided that you received this overpayment.

If you do not ask for a hearing on time, withdraw the hearing request or miss your hearing, you may lose your right to have one.This notice will be the final DHS decision (called a "final order by default"). You will not get a separate notice. The case file, along with any materials you submitted in this matter, is the record. The record is used to support the DHS decision upon default. You may appeal the final order by default by filing a petition in the Oregon Court of Appeals (ORS 183.482).If you do not ask for a hearing, this appeal must be filed within 60 days of the date this notice becomes a final order by default. If you withdraw a hearing request or miss your hearing, the appeal deadline is indicated in the dismissal order.

NOTE TO MILITARY PERSONNEL: Active duty service members have a right to stay at these proceedings under the federal Servicemembers Civil Relief Act (SCRA). For more information you may contact the Oregon State Bar (800-452-8260), the Oregon Military Department (800-452-7500) or the nearest legal assistance office.

(Agency representative)(Telephone number)

DHS will not discriminate against anyone. This means DHS will help all who
qualify. DHS will not deny help to anyone based on age, race, color, national origin,
sex, sexual orientation, religion, political beliefs or disability. You can file a complaint if
youthink DHS discriminated against you for any ofthese reasons.

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