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		Please Get the Exact Date of the Charge(if there was a Charge to their Debit/Credit Card).*

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		When did your illness/injury symptoms develop?*

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		What was the Total Amount Charged?*

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		Credit Card Info (Last 4 Digits Only):*

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		What were your illness/injury symptoms?*

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		What was the correct amount to be charged?*

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		What was the Expiration Date of the Credit Card:*

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		Did you seek medical treatment for you injury/illness??*

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		What is the Amount to be corrected?*

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		Was this a Debit or Credit Card?*

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		What was the Credit Card Type: (VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER or OTHER)*

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