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Notice: The Fairness Foundation is only providing information. Such information is not legal advice. Legal advice can only come from a duly-licensed attorney in your State. The Fairness Foundation encourages you to consult with an attorney on legal matters as there are time limits that could adversely affect your legal rights.
First Step - Request the Medicare Treatment Codes:
Use this letter ONLY if you have not been sent to collections, and
are dealing only with the hospital. If the hospital has sent you to
collections, or is threatening to do so, please use choose from
the next set of letters.
Print this page out, make copies, and send this letter to the hospital. For
your convenience this letter is also available in
WordŽ,
Rich Text File (RTF), or
plain text format.
Just fill in the information indicated, print, and mail by registered
mail.
[date]
[Institution Name]
[Institution Address]
[Institution City, State, ZIP]
[CFO Name]
Re: [Patient Name], Account [Patient Account Number], Date Admitted [Admittance
Date]
Dear Mr. [CFO Name]:
I am writing to request your full and thorough review of my account. I received
your balance due notice indicating I owe $[Amount Due] on the account. Please be
advised that I do not believe the charges to be a reasonable price for the
services rendered.
I am exercising my rights under HIPAA and demand that you provide me with a copy
of the UB-92 or UB-04 used to make decisions on my behalf and made
part of my designated record set. Under federal law (HIPAA), I am entitled to,
and I am demanding a copy of the financial responsibility agreement and
principle admitting, diagnosis, and treatment codes within 30 days of receipt of
this letter. If you fail to provide either document, I will file a complaint
with the Office of Civil Rights of the U.S. Department of Health and Human
Services and forward my complaint to the U.S. House Oversight and Investigations
Subcommittee.
I personally have a right by law to receive this information from you. I expect
you to comply. The requested information should be sent to my attention at the
address below. I will pay for any reasonable copy cost associated with this
request. Thank you for your prompt assistance with this matter.
I recently was informed of my rights and now will use all legal avenues to
protect myself from your unreasonable charges.
Please govern yourself accordingly.
signed
[Victim Name]
[Victim Address]
[Victim City, State, ZIP]
cc: The Fairness Foundation, Inc.
5835 West 74th Street
Indianapolis, IN 46278
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