Order Dispute Form
To dispute an order within 30 days of receiving your clearinghouse statement, please fill out this form. Please use your Clearinghouse statement as a reference for the required information. Once all the information is entered please click submit. A Customer Service Representative will contact you shortly regarding this dispute. Please be sure to fill in all required fields (marked with an orange asterisk).
The form number is located on the statement to the right of the order number and the sequence number is located on the statement to the right of the form number.