Dispute A Debt

Account Dispute Form

Please complete the dispute form below. Include as much information as possible to help us better understand your dispute.
Please enter the reference number found on your statement/notice in bottom right corner.
*ACCOUNT NUMBER IS REQUIRED FOR SUBMISSION*
*ACCOUNT NUMBER IS REQUIRED FOR SUBMISSION*
Please enter the reference found on your statement/notice in bottom right corner
First Name
*FIRST NAME IS REQUIRED FOR DISPUTE SUBMISSION*
*FIRST NAME IS REQUIRED FOR DISPUTE SUBMISSION*
Last Name
*LAST NAME IS REQUIRED FOR DISPUTE SUBMISSION*
*LAST NAME IS REQUIRED FOR DISPUTE SUBMISSION*
Birth Date
MM/DD/YY
Field is required!
Field is required!
Social Security Number
Social Security Number
Field is required!
Field is required!
Address Line 1
*ADDRESS REQUIRED FOR SUBMISSION*
*ADDRESS REQUIRED FOR SUBMISSION*
Address Line 2
Field is required!
Field is required!
City
*CITY REQUIRED FOR SUBMISSION*
*CITY REQUIRED FOR SUBMISSION*
State
*REQUIRED FOR SUBMISSION*
*REQUIRED FOR SUBMISSION*
Zip Code
*ZIP CODE REQUIRED FOR SUBMISSION*
*ZIP CODE REQUIRED FOR SUBMISSION*
Primary Phone Number
*REQUIRED FOR DISPUTE SUBMISSION*
*REQUIRED FOR DISPUTE SUBMISSION*
Cellular Phone Number
Field is required!
Field is required!
Email Address
Field is required!
Field is required!
Alternate Phone Number
Field is required!
Field is required!
Preferred Communication Method
*PREFERRED CONTACT METHOD IS REQUIRED FOR SUBMISSION*
*PREFERRED CONTACT METHOD IS REQUIRED FOR SUBMISSION*
I want to dispute the debt because I think:
*REASON FOR DISPUTE IS REQUIRED FOR SUBMISSION*
*REASON FOR DISPUTE IS REQUIRED FOR SUBMISSION*
What is your dispute? (Please include any details supporting dispute dates of service, payment dates/methods, locations etc.)
Description of Dispute is required
Description of Dispute is required for submission
Please provide a detailed explanation for dispute
Please provide any supporting documents (Invoices, Receipts, EOB Letters Etc)
Upload your documents...
Field is required!
Field is required!
*If you have any questions about this form please contact Central Professional Services so that we may assist you.1-800-748-0031
Field is required!
Field is required!
This dispute form has been completed to the best of my knowledge for submission to Central Professional Services:
Type your full name below approving this dispute
*NAME VERIFICATION IS REQUIRED FOR SUBMISSION*
*NAME VERIFICATION IS REQUIRED FOR SUBMISSION*
Your Full Name