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[date]
[Hospital Name]
[Hospital Address]
[Hospital City, State, ZIP]
[CFO Name]
Re:
[Patient Name], Account [Patient Account Number], Date Admitted [Admittance
Date]
Dear Mr.
[CFO Name]:
I am
writing to request your full and thorough review of my account. I received your
balance due notice indicating I owe $[Amount Due] on the account. Please be
advised that I do not believe the charges to be a reasonable price for the
services rendered.
To protect my credit worthiness, I am
submitting this letter under the Fair Debt Collection Practices Act (the “Act”).
Accept
this letter in accordance with applicable federal and state laws governing fair
debt collection practices. Take notice I am denying and disputing
any amount that you allege that I owe to [Hospital Name], and specifically deny
that I owe any amounts for fees, costs, and expenses of medical supplies,
services, diagnosis, or treatment in excess of their reasonable value.
I demand full and complete compliance with requirements of
the Act, and any similar or related state laws, and will, if necessary pursue
all available remedies and relief provided by law;
I deny and dispute any amounts that you allege that I owe to
[Hospital Name] and specifically deny that I owe any amounts for the fees,
costs, and expenses of medical supplies, services, diagnosis, or treatment in
excess of their reasonable value. I demand that you verify the validity of this
debt in writing within 30 days and submit a copy to me at the address below;
Do not contact me any further, except as expressly permitted
by law, at my home or place of employment regarding this disputed debt.
I am also
exercising my rights under HIPAA and demand that you provide me with a copy of
the UB-92 or UB-04 used to make decisions on my behalf and made
part of my designated record set. Under federal law (HIPAA), I am entitled to,
and I am demanding a copy of the financial responsibility agreement and
principle admitting, diagnosis, and treatment codes within 30 days of receipt of
this letter. If you fail to provide either document, I will file a complaint
with the Office of Civil Rights of the U.S. Department of Health and Human
Services and forward my complaint to the U.S. House Oversight and Investigations
Subcommittee.
I further demand
a copy of the [hospital name] charity care guidelines, and the specific reasons
for your non-profit hospital denying my financial assistance application.
I recently
was informed of my rights and now will use all legal avenues to protect myself
from your unreasonable
charges.
Please govern yourself accordingly.
signed
[Victim Name]
[Victim Address]
[Victim City, State, ZIP]
cc: The Consejo de Latinos Unidos
5835 West 74th Street
Indianapolis, IN 46278
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