The full sample letter.

Re: Account #4471-B — Formal dispute of billing errors and demand for validation and itemization

To Whom It May Concern:

I dispute the charges on the above-referenced account. Pursuant to the Fair Debt Collection Practices Act, 15 U.S.C. §1692g, the No Surprises Act, and applicable state law, I demand validation of this account and correction of the following:

1. Duplicate charge. CPT 99285 appears twice on the itemized statement, billed on the same date of service, for a combined $1,842.00. A single emergency-department evaluation cannot be billed twice. I demand removal of the duplicate line ($921.00).

2. Unitemized charge. The line "Supplies — misc" for $189.00 identifies no goods or services. I demand a fully itemized statement identifying each item, its CPT/HCPCS code, and its date of service. A charge that cannot be identified cannot be collected.

3. Facility fee verification. The emergency facility fee of $1,240.00 requires verification of network status under the No Surprises Act. If this visit is covered by the Act, I owe no more than the in-network cost-sharing amount, and I demand recalculation.

Until the above is resolved, I further demand that you:

• suspend all collection activity on the disputed amounts, as required during the validation period;
• refrain from reporting the disputed amounts to any credit bureau, or, if already reported, mark the account as disputed as required by law;
• respond in writing within 30 days of the date of this letter.

This letter was sent by USPS certified mail with return receipt. The delivery record and this letter form part of the written record of this dispute.