Provider Payment - Errors and Disputes

Provider Payment - Errors and Disputes

Provider Name*

Provider email*

To what email address should we send communications regarding this dispute?

Dispute Type*

Select what went wrong

Select

Task ID*

CareCar Task ID

Task Status*

Was the ride completed?

Select

Date of Service*

When was the ride completed or scheduled?

Member Name

Notes to CareCar

Additional notes detailing the issue or dispute

File Upload

Please include any relevant documentation to support your dispute

Drag and drop files here or

Send me a copy of my responses