Name: Address: City & State: Zip: Daytime Phone:

Date: Medical Provider's Name: Contact Person: Address: City & State: Zip: RE: Balance Billing Practice (Acct. Number)__________

To Whom It May Concern:

On (Date), I received a bill for (specified medical service e.g. doctors appointment, laboratory work, preventive health service, etc...). These services were provided to me on (date services provided)

This letter is to inform you that the above mentioned medical services are covered by my health care service plan. My health care service plan is provided by (name). It is my understanding that my plan covers these services. If (health care service plan provider) has denied that the above mentioned services are covered. Please provide me with a copy of all relevant documentation of denial.

If (health care service plan provider) has determined that your fee is unreasonable and has paid or offered to pay a lower fee your dispute is with them.

For the above mentioned reason I dispute that I owe this debt. Please contact my health care service plan provider to resolve your billing dispute with them. I suggest you contact the California Department of Managed Health Care if you are having difficulty resolving this dispute with my health care service plan provider.

I look forward to your reply informing me that you will no longer be attempting to bill me for the above mentioned medical services. If it is still your position that I owe the above mentioned debt please send me a copy all relevant billing information including all correspondence you have had with my health care service plan provider and your billing methodology.

Please respond in writing within thirty (30) days. I will wait thirty (30) days before seeking third-party assistance to resolve this billing dispute. Please contact me at the above address or by phone.

Sincerely,

(Your name)

Cc: Department of Managed Health Care, Complaint Unit, 980 9th St., Suite 500, Sacramento, CA 95814

Keep copies of your letter and all related documents. Send your letter by certified mail, return receipt requested. DO NOT send original documents.