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(Date of Letter)

(Hospital/Care Provider) (Street Address) (City, State and Zip Code) RE: (Account Number) Attn: Accounting Department

Dear Accounting Department: Recently the undersigned received a statement for services on behalf of (name of individual for whom medical care was provided). The statement for services indicated that $ (amount) was due for medical services rendered for the aforementioned individual. As you should know from your records, medical health insurance was provided through (name of insurance carrier). It is my understanding that of the total amount indicated to be due above, the sum of $ (amount paid by insurance) was paid by the insurance carrier. This would indicate that the balance due of $ (balance remaining after insurance payment) remains unpaid. You have requested payment of the balance due from the undersigned. Please verify that this amount is remaining unpaid and due after insurance coverage has been received. If this is the balance remaining unpaid, please be advised that the undersigned will tender immediate payment; however, clarification of this amount is necessary due to the fact that the extent of insurance coverage is now at issue. Your immediate clarification and cooperation relative to the resolution of this outstanding bill will be appreciated. Kindly contact the undersigned at the address and/or phone number listed below. Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number) LAWCHEK, LTD. LETTER PRO Samples, Copyright 2000 This is not a substitute for legal advice. An attorney must be consulted.