[TODAY'S DATE]
To the billing department at Sample General Hospital (fictional),
Re: account [ACCOUNT OR BILL NUMBER] · date of service [DATE OF SERVICE] · patient [YOUR FULL NAME]
I've reviewed the bill for the account above and I'm writing to dispute specific charges. Please pause collections on this account while you investigate; California law prohibits adverse credit reporting on medical debt, and I'm asking for written confirmation that no further collection activity will occur until this is resolved.
Duplicate charges.
The following line(s) appear more than once on the bill with the same description and amount. Please confirm in writing whether each is a separate, distinct service, or remove the duplicate(s) from the balance:
• CT scan abdomen w/ contrast — $3,150.00
Please send a written response, including a corrected statement, within 30 days. If you need a copy of my insurance card or any other information to investigate, write to me at the address above.
Thank you.
[YOUR FULL NAME] [YOUR MAILING ADDRESS]