Free Medical Bill Dispute Letter Template
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:
-
Service Description: General Consultation
Billed Amount: $350.00
Expected Amount: $250.00 -
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]
