Patient letters
Pick the letter that fits, fill in the blanks, then copy or download it. Everything stays on your device — nothing you type is sent or saved. These are templates, not legal advice.
Not sure which letter you need? See the Patient Letter Hub. Appealing an insurance denial? Use the appeal letter builder. Asking for charity care? Use the financial assistance letter.
Surprise (balance) bill dispute
- Law:
- No Surprises Act, 42 U.S.C. §300gg-131 and §300gg-132; 45 C.F.R. Part 149
- Timing:
- Act quickly. You can also call the federal No Surprises Help Desk at 1-800-985-3059.
- Send to:
- The provider who billed you; send a copy to your health plan.
Your letter
[Your name] [Your address] [Date] [Recipient name and address] Re: Dispute of balance bill under the No Surprises Act Account/Reference: [Account number] I received a bill for care on [date of service] at [facility]. I believe this care is protected by the No Surprises Act, which limits what I owe to my in-network cost sharing for emergency services and for certain out-of-network care at in-network facilities. Please review this bill, correct it to my in-network cost-sharing amount as shown on my plan’s Explanation of Benefits, and refund any amount I paid above it. If you believe the law does not apply, please explain why in writing and include any notice-and-consent form I signed. Please hold the account from collections during this review. Sincerely, [Your name]
Keep a copy and send by certified mail with return receipt when you can. Replace anything in [brackets] before sending.