Bill Pushback[Your name]
[Your mailing address]
[Today's date]
[Billing office name]
[Billing office address]
Re: Dispute of charges. Patient: [Patient name]. Account: [Account number]. Date of service: [Date of service].
To the billing office:
I have reviewed the itemized bill for the account above, and I dispute the following charges:
[List each charge: its date, code, amount and why it is wrong (billed twice, not received, wrong code, should have gone to insurance)]
Please review these charges, correct the bill, and send me a corrected itemized bill. If you believe a charge is correct, please explain it in writing and send the records that support it.
Please place this account on hold, and do not send it to a collection agency, while this dispute is open.
Thank you,
[Your name]
