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

Task ID *

CareCar Task ID

Task Status *

Was the ride completed?

Date of Service *

When was the ride completed or scheduled?

mm/dd/yyyy

Member Name

Notes to CareCar

Additional notes detailing the issue or dispute

File Upload

Please include any relevant documentation to support your dispute

Drop your files here

*

Send me a copy of my responses