Charge Dispute Form

Indiana Health Group

Charge Dispute Form

Patient's Name*

First Name

Initial

Last Name

Name of person completing this form (if different from patient):

First Name

Initial (optional)

Last Name

Patient's Birth Date*

Phone*

Missed Appointment Late Cancellation Late Arrival

Other:

Reason for dispute:*

Preferred Method of Contact*

Email Address

Home Address

Address Line 1

Address Line 2

City

State

ZIP Code

Please allow up to one week for processing.

Your dispute will be reviewed by our office manager.

If a decision is made to waive the charge it will be automatically removed from your account & notification will not be sent.

Only if the dispute is denied will you be notified by email.

Please note: Therapist, doctors, nurses, clerical staff, and/or billing department personnel are unable to waive or modify fees.