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REQUEST FOR BILLING REVIEW (Billing Inquiry/Disputes)
* Required Fields
 
 
CUSTOMER:  
RE:  INVOICE #: *  
BILLING PERIOD:    
CONTACT :  
DATED: *  

 

Please note “Terms and Conditions” of Invoice/Credit policy.  All questions of charges billed on the above reference invoice must be submitted to OHM Systems Inc. within fourteen (14) days of the invoice date.  A manual deduction off an invoice by a customer is not an official credit.  And the  amount not in dispute must be paid within the Invoice terms.

 

You may fax or mail this paper to our office to the attention of the Billing Department.

 

Please attach any information that would be helpful in referring to the comments below.

 
DATE OF SERVICE REFERENCE SERVICES PROVIDED YOUR CONCERN/DISPUTE
     
 
AMOUNT OF DISPUTE: $ 
DATE:  
   
FORM SUBMITTED BY:  
TITLE:  
   
RECEIVED:  
BY:  
   
ACTION TAKEN:
 
 
 
 
 
     
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