Medical Bill Dispute Letter

[Your Name]

123 Elm Street
Springfield, IL 62704
[Your Email]

September 17, 2050

Billing Department
EyeFusion

Phoenix, AZ 85001

Subject: Dispute of Medical Bill for Account #789456

Dear Billing Department,

I am writing to formally dispute the charges on the medical bill dated September 10, 2050. After a thorough review, I have identified discrepancies where certain services were billed at a higher rate than what was agreed upon or expected.

Specifically, I have concerns regarding the following charges:

1. Service Description: General Consultation
   Billed Amount: $350.00
   Expected Amount: $250.00

2. Service Description: X-Ray Imaging
   Billed Amount: $200.00
   Expected Amount: $150.00

The charges listed above do not match the rates discussed during my appointment or the amounts indicated in my prior agreement with your office. I kindly request a detailed review and correction of these charges to reflect the correct amounts.

Attached to this letter are copies of relevant documents, including the original bill, a copy of the service agreement, and correspondence from my insurance company which supports this dispute.

Please address this issue promptly and provide a revised bill or an explanation within 30 days of receiving this letter. I appreciate your immediate attention to this matter and look forward to your response.

Thank you for your cooperation.

Sincerely,

[Your Name]

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