Client Dispute

Dispute Resolution Form

* Indicates required field

Company Name *

Your Name *

First

Last

Phone Number *

Your Email *

Select Type of Dispute *

Intake Date and/or Invoice Number *

Name/Names of Client *

Please explain what you are disputing and why. *

Please state the resolution you are looking for. *

Upload Docs/Intake / Invoice *

Max file size: 20MB

Submit Dispute

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Sat - Sun:
By Appt.

Toll-Free 1-800-210-9812 Ext. 0
Fax: 219-627-9200
Email: [email protected]
Docs: [email protected]
Scheduling: [email protected]

Headquarters -
16 W Main St. Ste 284 LaCrosse, IN 46348

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