DECCD Provider Report of Underpayment/Overpayment Form

Please use this form to report any problems with an over-payment or under-payment. Payment adjustment request MUST be submitted within 10 days of the disputed payment in order to be processed. NOTE: Sign In/Out Sheets must be submitted in addition to this form.

If YES, Sign In/Sign Out Sheets must be submitted to DECCD. You may send documents through FAX, EMAIL, POSTAL MAIL or UPLOAD to this form.

Example: John Doe, June, 1 through 15

Fax Number: 601-359-4422

Email Address:

Mailing Address:
P. O. Box 352
Jackson, MS 39205

If you would like to upload a copy of any document(s) that are required for the specific change you are trying to make, please upload the document(s) here.

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