SAMPLE — FICTIONAL DATA. NOT A REAL LETTER.

April 21, 2025
To: Patient Financial Services, Seaside Regional Hospital

Billing dispute: amount does not match my insurance

Dear Patient Financial Services team,

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)). Florida Statutes 395.301

Attached: Copy of the Explanation of Benefits.

Sincerely,
Daniela Castillo
9349 Seagrape Ln Apt 717
Bayside, FL 33067
(954) 555-0161
Signature
Where this comes from (for you, not part of the letter)
  • Florida Statutes 395.301, 2026, page 1: The facility must provide an initial response to a patient grievance within 7 business days after the patient formally files a grievance disputing all or a portion of an itemized statement or bill.
Save PDF

You review and sign every letter.