Download "Negotiate Your Balance" Word Document
Appeal Letter Displayed for your convenience
Health Symphony Appeal Letter
To Negotiate Your Balance
Your name, address and phone number
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.
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:___________