The full sample letter.

Re: Account #4471-B — Dispute of billing charges and request for documentation

To Whom It May Concern:

I dispute the accuracy of the charges identified below and request documentation sufficient to explain and substantiate them. I ask that you review the account and correct 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. These two entries appear potentially duplicative. Please identify the separate services, timestamps and billing components represented by each entry, or remove any duplicate charge ($921.00).

2. Unitemized charge. The line "Supplies — misc" for $189.00 identifies no goods or services. Please provide a fully itemized statement identifying each item, its CPT/HCPCS code, and its date of service. I dispute this charge until the goods, services and basis for the amount are clearly itemized.

3. Facility fee. The emergency facility fee of $1,240.00 requires confirmation of network status. If the No Surprises Act applies to this visit, my responsibility is generally limited to in-network cost sharing, and I request that the balance be recalculated accordingly.

While this dispute is under review, I request that you:

• place the disputed amounts on hold and do not refer the account to collections;
• do not report the disputed amounts to any credit bureau while they remain in dispute.

I would appreciate a written response within 30 days of the date of this letter. If I have not received one by then, I will follow up in writing.

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.