Asset Systems, Inc.

Helping not-for-profit hospitals find balance

Dispute a Bill

To dispute a bill, please complete the following form.

Fields marked in red are required.

Please enter your ASI account number (if known):

Please enter your full name

(Required)

First Name:	*
Last Name:	*
MI:	*

(Required)

Is the bill you are disputing for yourself?	*
If "No," are you a...
If disputing on behalf of a business, enter business name below:

Enter disputing party´s address:

(Required)

Address Line 1:	*
Address Line 2:
City: * State: * Zip: *

Enter additional address (if any):

Address Line 1:
Address Line 2:
City: State: Zip:

(Required)

Phone Number: *

Type of phone: Home Work Cell Other

May we contact you at this number? Yes No

(Required) Enter your email address: ‹ Enter valid email

How may we contact you?: Phone Email Both

(Required) Please describe in detail your reasons for disputing this bill: *

I would like a copy of this dispute sent to my email address:

By clicking "Submit," I acknowledge that Asset Systems, Inc. is a collection agency and any information obtained will be used for the purpose of collecting a debt.

Hours

8:00AM - 4:30PM
Monday - Friday

Portland

P: 503.233.0462
TF: 800.553.2406

Federal Way

P: 253.838.2971
TF: 800.553.2406