ACCOUNTS RECEIVABLE DISPUTE

PHM | ACCOUNTS RECEIVABLE DISPUTE

If you would like to download this form to fax it "CLICK HERE"

***All Accounts Receivable Disputes must be brought within 30 days of date of disputed charge.***

Date / MM / DD YYYY
Member Name First Last
Member Account Number
Member Email
Contact Phone Number
Date of Disputed charge / MM / DD YYYY
Amount of disputed charge
Please explain your dispute providing all pertinent facts