About this form

This form is to be used to repay the Explanation of Benefits (EOB) with overpayment Letter requesting the return of the overpayment to DCMWC.

Please note that overpayment submissions should only be made if there is a related Transaction Control Number (TCN), as well as a specific request from DCMWC to return the overpayment. Overpayment submissions without the TCN will be rejected.

Accepted Payment Methods:

• Bank account (ACH)
• PayPal account
• Debit card