[date]

[recipient name]
[recipient address]

Re: Formal Dispute of Medical Bill — $[bill amount]

To Whom It May Concern:

I am formally disputing the above medical bill in the amount of $[bill amount]. Insurance status: [insurance status].

Basis for the dispute: [dispute reason].

Facts:
[facts]

Requested resolution:
[desired outcome]

I request an itemized statement listing every charge with its CPT/HCPCS code, a copy of any explanation of benefits relied upon, and a written response within thirty (30) days. Under the No Surprises Act and applicable state balance-billing protections, I am not responsible for out-of-network amounts beyond my in-network cost share. Please place this account on hold and refrain from reporting it to any consumer reporting agency while the dispute is pending.

Sincerely,

[user full name]
[user address]