[Your Name] [Street Address] · [email] · [phone] June 28, 2026 Billing Department Mercy General Hospital Re: Account #884217 — Disputed charge, date of service 03/03/2026 To the Billing Department, I am writing to formally dispute a charge of $1,840.00 on the above account. I was treated at your in-network facility on March 3, 2026, yet this bill applies out-of-network rates. I believe this is a billing error. Please take the following steps: 1. Send a fully itemized bill listing each charge by its CPT/billing code. 2. Re-process the claim at in-network rates, as the facility is in my plan's network. 3. Place this account on hold from collections while the dispute is reviewed. Under the federal No Surprises Act, patients are generally protected from surprise out-of-network charges for care at in-network facilities. Please confirm in writing how this charge complies. I am ready to pay any amount I genuinely owe once a corrected, itemized bill is provided. Please respond within 30 days. If this remains unresolved, I will pursue my insurer's appeals process and file with the CFPB and my state insurance regulator. Sincerely, [Your Name] --- PHONE SCRIPT (if you call instead): 1. "I'm disputing account #884217 — an $1,840 charge from March 3." 2. "I was treated at an in-network facility, so this out-of-network rate looks like an error." 3. "Please send an itemized bill and reprocess the claim at in-network rates." 4. "Can you put the account on hold from collections and give me a reference number for this call?" (Drafting + plain-English help only — not legal or financial advice.)