Free Nursing Home Billing Dispute Form Template
Nursing Home Billing Dispute Form
At [Your Company Name], we strive for accuracy and transparency in all our billing practices. If you find any discrepancies or errors in your billing statement that you would like to dispute, please fill out this form. Your concerns are important to us, and we are committed to resolving them promptly.
Billing Dispute Form
|
Field |
Information to be Filled |
|---|---|
|
Resident's Full Name: |
|
|
Account Number: |
|
|
Date of Billing Statement: |
|
|
Disputed Amount: |
$150.00 |
|
Description of Dispute: |
Charged for physical therapy sessions not attended |
|
Desired Outcome: |
Refund of disputed amount |
|
Contact Phone Number: |
|
|
Contact Email Address: |
Instructions:
-
Please complete each field with accurate information related to the disputed billing entry.
-
Describe the nature of your dispute clearly and specify the desired outcome.
-
Attach any relevant documents or evidence that support your dispute (e.g., receipts, correspondence).
Please sign below to confirm the authenticity of the information provided and your intent to dispute the designated charges. We will review your submission and contact you within 10 business days to address your concerns.
Signature:
Date:
