“I received your balance due notice indicating I owe $[Amount Due] on the account. Please be advised that I do not believe the charges to be a reasonable price for the services rendered.”
[Hospital City, State, ZIP]
Re: [Patient Name], Account [Patient Account Number], Date Admitted [Admittance Date]
Dear Mr. [CFO Name]:
I am writing to request your full and thorough review of my account. I received your balance due notice indicating I owe $[Amount Due] on the account. Please be advised that I do not believe the charges to be a reasonable price for the services rendered.
To protect my credit worthiness, I am submitting this letter under the Fair Debt Collection Practices Act (the “Act”).
Accept this letter in accordance with applicable federal and state laws governing fair debt collection practices. Take notice I am denying and disputing any amount that you allege that
I owe to [Hospital Name], and specifically deny that I owe any amounts for fees, costs, and expenses of medical supplies, services, diagnosis, or treatment in excess of their reasonable value.
I demand full and complete compliance with requirements of the Act, and any similar or related state laws, and will, if necessary pursue all available remedies and relief provided by law;
I deny and dispute any amounts that you allege that I owe to [Hospital Name] and specifically deny that I owe any amounts for the fees, costs, and expenses of medical supplies, services, diagnosis, or treatment in excess of their reasonable value. I demand that you verify the validity of this debt in writing within 30 days and submit a copy to me at the address below;
Do not contact me any further, except as expressly permitted by law, at my home or place of employment regarding this disputed debt.
I am also exercising my rights under HIPAA and demand that you provide me with a copy of the UB-92 or UB-04 used to make decisions on my behalf and made part of my designated record set. Under federal law (HIPAA), I am entitled to, and I am
demanding a copy of the financial responsibility agreement and principle admitting, diagnosis, and treatment codes within 30 days of receipt of this letter. If you fail to provide either document, I will file a complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services and forward my complaint to the U.S. House Oversight and Investigations
I further request a copy of [hospital name] charity care guidelines.
I recently was informed of my rights and now will use all legal avenues to protect myself from your unreasonable charges.
Please govern yourself accordingly.
[Victim City, State, ZIP]
cc: The Consejo de Latinos Unidos
5835 West 74th Street
Indianapolis, IN 46278
Editor’s Note: Being hasseled by hospital balance billing? As long as the claim is disputed, your credit is protected. For more information, go to http://www.hospitalvictims.com/hv_defend3.asp. Cost Plus Insurance utilizes consumer rights to the fullest extent that the law provides – www.costplusinsurance.com. Also see Federal Judge Rules In Favor Of Cost Plus Insurance
How To Negotiate With Hospitals – Step 2………… coming soon to this blog