Negotiate Your Balance Appeal Letter Free Download


Negotiate Your Balance

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Health Symphony Appeal Letter

To Negotiate Your Balance

Your name, address and phone number

Date

Medical Provider’s Address

Dear Dr _________:

I am writing to you in regards to a bill I received in the amount of [Dollar Total] for a medical service I received on [Date].

As I do not have a health plan I am requesting a substantial discount on the amount currently owed to you. I am willing to pay $__________ in ____ monthly payments of $_______. I realize that individuals who have health insurance are not expected to pay the full balance, as their health plan will pay a negotiated fee or will apply their Usual and Customary Reduction on the balance owed. These discounts off of your balance can be as much as 80%.

I have also performed some additional research on Cash Pay Patients who have balances due with their physicians, and a standard Cash Pay Discounts can range between 60 to 80%. I am requesting a discount of ___%. I believe this is a fair amount to pay.

Please honor my discount request and contact me at your earliest convenience or sign this document below if you agree to accept this negotiated fee. If I do not hear from you within 30 days, I will contact you again. Please do not initiate any collections activity until you have contacted me directly as I fully intend to pay what is fair and appropriate and would like to work out a payment arrangement with you.

Thank you for your time and assistance in this matter.

Sincerely,

[Patient Name]

I agree to pay the total amount of $________ in ___ monthly payments of $_____.

Patient Signature: _________________________________ Date:___________

We agree to accept this payment arrangement:

Provider’s Signature:______________________________ Date:___________