Medical Billing Dispute Letter (Free Sample)
Use this sample medical billing dispute letter as a template for your formal dispute letter.
Last updated on July 19th, 2022
Sample Medical Billing Dispute Letter
Patient’s Name
Patient’s Address
City, State, Zip Code
Patient’s Bill or ID Number
DATE
Hospital or Doctor’s Name
Billing Department
Hospital or Doctor’s Address
City, State, Zip Code
Dear Name of Billing Officer:
This letter is to formally inform you that the bill you gave me for treatment in your hospital on DATE is inaccurate. I received treatment for a broken arm after an automobile accident on that day.
Technicians took x-rays and set my arm, at which time I was discharged. The bill you gave me lists an MRI scan for the cost of AMOUNT, which I didn’t have.
I have included a copy of the bill with the MRI cost highlighted. I have also included the record of treatment given to me when I was discharged. As you can see, I did not receive an MRI scan.
Based on this information, I request that you send me a new bill that excludes the cost of an MRI scan. I have sent this request within the 30 day limit according to the instructions given to me by you for billing disputes.
I hope to hear from you within two weeks from the date you receive this letter. I can be reached at 555-123-4567 or at [email protected]
Thank you for you quick attention to this matter.
Sincerely,
Signature of Patient
Printed Name of Patient
Patient’s Billing or Treatment Number
List of Enclosures
By Andre Bradley
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