Stop Payment Processing Form

Hi there! If the check you sent to ChartRequest was not delivered timely enough for your needs, please complete the form below to ensure you are not charged a penalty for your Stop Payment nor have a freeze placed on your account due to Stop Payment notice not being provided. We have have this form completed prior to any Stop Payments being issued. Otherwise, per the our Terms of Service there will be fees incurred.

Please complete the form below

This number can be found on your invoice.
ie. Primary Care Practice, or NY Radiology
Let us know how to help!
Your Name *
Your Name