Medical Debt Collection Dispute Demand Letter

[Your Name]
[Your Address]
[City, State ZIP]
[Email]

[DATE]

[Medical Debt Collector or Provider]
[Address]
[City, State ZIP]

RE: MEDICAL DEBT DISPUTE - VALIDATION REQUIRED - Account No. [ACCOUNT NUMBER]

Dear Sir or Madam:

This letter concerns your attempt to collect medical debt allegedly owed to [PROVIDER/FACILITY NAME] for services on [DATE(S) OF SERVICE].

Pursuant to FDCPA § 809(b) (15 USC § 1692g(b)), I dispute the validity of this debt and demand verification.

Debt Information:
Provider/Facility: [NAME]
Date(s) of Service: [DATE(S)]
Amount Claimed: [AMOUNT]
Your Reference Number: [REFERENCE NUMBER]

I dispute this debt for the following reasons:

[SELECT AND CUSTOMIZE APPLICABLE DISPUTES:]

☐ SURPRISE BILLING / NO SURPRISES ACT VIOLATION:
[For emergency care:] This debt relates to emergency services I received at [FACILITY]. Under the No Surprises Act (2021), I am protected from surprise bills for emergency care and can only be billed in-network cost-sharing amounts, regardless of whether the provider was in-network. The amount you claim exceeds my in-network cost-sharing obligation and violates federal law.

[For out-of-network provider at in-network facility:] This debt involves services by [PROVIDER NAME], an out-of-network provider, at [FACILITY NAME], which is in my insurance network. Under the No Surprises Act, I am protected from balance billing in this situation and can only be billed in-network amounts. The provider must resolve payment disputes with my insurer through arbitration, not by billing me.

☐ INSURANCE NOT PROPERLY BILLED OR PROCESSED:
You are attempting to collect this debt without properly billing my insurance or processing the claim. My insurance information at the time of service was:
Insurer: [INSURANCE COMPANY]
Policy Number: [POLICY NUMBER]
Group Number: [GROUP NUMBER if applicable]

I provided this insurance information to [PROVIDER] at the time of service. [The provider never billed my insurance / The provider billed insurance incorrectly / I never received an Explanation of Benefits (EOB) showing insurance processing]. You cannot send medical debt to collections without first properly processing insurance claims and providing me the opportunity to review the EOB.

☐ NO ITEMIZED BILLING PROVIDED:
You have demanded payment but have not provided an itemized bill showing what services were rendered and why I allegedly owe this amount. I am entitled to an itemized bill containing:
- Date(s) of each service
- Specific procedures/treatments with CPT codes
- Charge for each service
- Insurance payments applied to each charge
- Explanation of Benefits (EOB) from insurer
- Calculation showing my financial responsibility

Without this documentation, I cannot verify the debt is accurate or that I am actually liable.

☐ BALANCE BILLING PROHIBITED BY STATE LAW:
This debt involves balance billing for [emergency services / in-network facility services / other protected services] in [YOUR STATE]. State law prohibits balance billing for these services under [cite state statute if known]. You cannot collect amounts that violate state balance billing protections.

☐ BILLING ERRORS:
The bill contains errors, including [CHECK ALL THAT APPLY]:
- Duplicate charges for the same service
- Services billed that were not actually provided
- Incorrect patient information (wrong patient, wrong date of service)
- Charges exceeding the provider's contracted rate with my insurer
- Upcoding (billing for more expensive procedure than was performed)
- Other: [DESCRIBE]

☐ INSURANCE PAID - BALANCE INCORRECTLY CALCULATED:
My insurance company paid this claim. According to my EOB dated [DATE], insurance paid $[AMOUNT] and my patient responsibility is $[AMOUNT]. Your claim of $[HIGHER AMOUNT] is incorrect. [If applicable: I already paid my patient responsibility amount of $[AMOUNT] on [DATE].]

Under FDCPA § 809(b), you must cease all collection activity until you provide verification of this debt. For medical debt, adequate verification requires:

1. Complete itemized billing with CPT codes for all services;
2. Proof that services were actually rendered to me;
3. Proof that my insurance was properly billed and processed;
4. Explanation of Benefits (EOB) from my insurer;
5. Calculation showing how you arrived at the amount claimed, including what insurance paid;
6. Proof that I am liable for the remaining balance under my insurance policy and applicable law;
7. If claiming No Surprises Act doesn't apply, documentation showing why; and
8. Any applicable state balance billing law compliance.

I also demand:
1. That you immediately contact [PROVIDER] and instruct them to properly bill my insurance (if not yet done);
2. That you not report this debt to credit reporting agencies until it is verified;
3. That you remove this debt from my credit report if already reported; and
4. Written confirmation of the above.

Be advised that medical debt collection is subject to heightened scrutiny. Collecting amounts prohibited by the No Surprises Act, state balance billing laws, or that were not properly processed through insurance may violate both federal and state law.

Failure to cease collection and provide adequate verification violates FDCPA § 809(b) and subjects you to statutory damages up to $1,000, actual damages, and attorney fees under § 813 (15 USC § 1692k).

All future communications must be in writing to the address below.

Sincerely,

[Your Signature]
[Your Printed Name]