"Medical Bill Dispute Letter Template"

What Is a Medical Bill Dispute Letter?

A Medical Bill Dispute Letter is a document that can be used by individuals who disagree with the information presented in their medical bill and want to dispute it. The purpose of the document is to provide the medical organization that has issued the bill with information that this document contains errors and request them to fix those errors.

A printable Medical Bill Dispute Letter template can be found through the link below.

Medical bills can contain different types of errors, such as typos, duplicate charges, charges for canceled procedures, etc. Generally, a dispute letter for a medical bill is supposed to be submitted to the billing department of the medical organization that has issued the bill.

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How to Write a Medical Bill Dispute Letter?

A Medical Bill Dispute Letter can be written and sent by the individual who disputes the bill or their representative and can contain several parts. These parts can include the following:

  1. Information About the Addressee. In the first part of the letter, the sender can state the identifying information about the medical organization that has issued the bill in question (the addressee). It can include their name and location.
  2. Information About the Sender. Here the sender is supposed to designate their personal information for identification purposes. It can consist of their full name, address, and telephone number. This information can also be used by the addressee in case they will have any questions concerning the matter.
  3. Date. Official letters that request their addressee to commit certain actions should always include the date they were written. It will show that the letter is current and can help in defining the time period for a response.
  4. Introduction. The sender can use this part of the letter to introduce themselves and explain the purpose of writing. They can also indicate the information about the bill in question, including the date of issuing and the bill identification number.
  5. Disputed Subject. This part can be used by the sender to describe all of the errors that were made in the medical bill. The sender can present it in the form of a comparison, where they will state the wrongful information from the bill and the right information that is supposed to be there. If applicable, the sender can attach documents that can prove they are right and can be used as evidence.
  6. Conclusion. Senders should use this part of the letter to request the addressee to fix the errors in the bill, make a correct statement, and return any amounts that have been wrongfully charged (if the services have already been paid for).
  7. Signature. To validate that the information presented in the document is true and correct the sender should sign it.

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Medical Bill Dispute Letter
From: ​ _ __________________________
To:​ _ _____________________________
Patient’s Name
Hospital or Doctor’s Name
_________________________________
_________________________________
Patient’s Bill or ID Number
Billing Department
_________________________________
_________________________________
_________________________________
_________________________________
Patient’s Address
Hospital or Doctor’s Address
_________________________________
_________________________________
City, State, ZIP Code
City, State, ZIP Code
_________________________________
D ate
Dear ____________________________,
Name of Billing Officer
This letter is to formally inform you that the bill you gave me for treatment in your
hospital on ______________________ is inaccurate. The amount is in error due to the
following:
_____________________________________________________________________
_____________________________________________________________________
Based on this information, I request that you send me a new bill that excludes the cost
of ______________________. I have sent this request within the _________-day limit
according to the instructions given to me by you for billing disputes.
I hope to hear from you within ______________________ from the date you receive
this letter. I can be reached at [​
P hone Number​
] or at [​
E mail​
] .
Thank you for your quick attention to this matter.
Sincerely,
_______________________________
Patient’s Name
_______________________________
Patient’s Signature
© ​
T EMPLATEROLLER.COM
Medical Bill Dispute Letter
From: ​ _ __________________________
To:​ _ _____________________________
Patient’s Name
Hospital or Doctor’s Name
_________________________________
_________________________________
Patient’s Bill or ID Number
Billing Department
_________________________________
_________________________________
_________________________________
_________________________________
Patient’s Address
Hospital or Doctor’s Address
_________________________________
_________________________________
City, State, ZIP Code
City, State, ZIP Code
_________________________________
D ate
Dear ____________________________,
Name of Billing Officer
This letter is to formally inform you that the bill you gave me for treatment in your
hospital on ______________________ is inaccurate. The amount is in error due to the
following:
_____________________________________________________________________
_____________________________________________________________________
Based on this information, I request that you send me a new bill that excludes the cost
of ______________________. I have sent this request within the _________-day limit
according to the instructions given to me by you for billing disputes.
I hope to hear from you within ______________________ from the date you receive
this letter. I can be reached at [​
P hone Number​
] or at [​
E mail​
] .
Thank you for your quick attention to this matter.
Sincerely,
_______________________________
Patient’s Name
_______________________________
Patient’s Signature
© ​
T EMPLATEROLLER.COM