[date]

[Institution Name]
[Institution Address]
[Institution City, State, ZIP]
[CFO Name]

Re: [Patient Name], Account [Patient Account Number], Date Admitted [Admittance Date]

Dear [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. 

I am exercising my rights under HIPAA and demand that you provide me with a copy of the UB-92, UB-04, or CMS-1450, CMS-1500, or Form 837 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 principal 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 personally have a right by law to receive this information from you. I expect you to comply. The requested information should be sent to my attention at the address below. I will pay for any reasonable copy cost associated with this request. Thank you for your prompt assistance with this matter.

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, Inc. 
5835 West 74th Street
Indianapolis, IN 46278