SAMPLE - FICTIONAL DATA

April 21, 2025

Patient Financial Services, Seaside Regional Hospital

Subject: Billing dispute: amount does not match my insurance

My statement for account 44932556 lists the same service twice: lines 1 and 2, code 01960, on February 11, 2025, $4,944.00 each. Please remove the duplicate and the charge to me for it.

Please correct the balance, or explain it in writing. Florida law asks the hospital to give a first response to a billing dispute within 7 business days (Florida Statutes 395.301(6)).

Attached: Copy of the Explanation of Benefits

Sincerely,

Daniela Castillo
9349 Seagrape Ln Apt 717
Bayside, FL 33067
(954) 555-0161