Charge Dispute Form | Indiana Health Group

Patient's Name:(Required)

First Middle Initial (Optional) Last

Name of Person Completing This Form (If Different from Patient):

First Middle Initial (Optional) Last

Patient's Date of Birth:(Required)

Phone:(Required)

Disputed Charge:(Required)

Missed Appointment

Late Cancellation

Late Arrival

Other

Reason for Dispute:(Required)

Preferred Method of Contact:(Required)

Email:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

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.