Billing Dispute Notification Form For Centrally Billed ... - Jefferson Lab - jlab 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. In Section 1, enter your Agency/Organization Name and Central Account Number. Ensure accuracy as this information is crucial for processing your dispute.
  3. Proceed to Section 2. Fill in the Transaction Information by providing the Dollar Amount, Reference Number, Transaction Date, and Posting Date for each disputed transaction.
  4. Select the appropriate Reason Code that best describes your dispute from the options provided. This helps clarify the nature of your inquiry.
  5. In Section 3, add any additional Remarks that may assist in resolving your dispute. Be detailed about previous communications with merchants if applicable.
  6. Finally, complete Section 4 by signing and providing your contact information to certify the accuracy of the information submitted.

Start using our platform today to streamline your billing disputes effortlessly!

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