This form is to be used when a collection company is demanding full payment from you and you disagree with the balance. Use this form as your first letter of dispute.
Dispute Letter Template
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Free preview credit dispute letter pdf
How to fill out Arizona Letter Of Dispute - Complete Balance?
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FAQ
Arizonans are now better protected from surprise out-of-network medical bills after the No Surprises Act, a federal law backed by Arizona Senator Mark Kelly, went into effect starting on January 1, 2022.
I am writing to dispute a charge of $ to my credit or debit card account on date of the charge. The charge is in error because explain the problem briefly. For example, the items weren't delivered, I was overcharged, I returned the items, I did not buy the items, etc..
If both your insurer and your provider won't amend the bill, you should submit an official complaint. The federal government has a new process for you to report suspected surprise medical bills. You can do so online or by phone at at 1-800-985-3059. In the meantime, your provider could submit your bill to collections.
Consumers can dispute fraudulent charges on their bill by calling their issuer. This is typically a quick process where the issuer will cancel the credit card in question and reissue a new one. You also have the right to dispute a credit card charge for a purchase you willingly made.
Patients can only be required to pay in-network costs for these services. The law also prohibits balance billing which would leave patients on the hook for covering the difference between the provider's charge and what insurance covers.
If you believe you've been wrongly billed, you may contact the Arizona Department of Insurance and Financial Institutions at 1 (602) 364-3100. Visit for more information about your rights under federal law or call 1 (800) 985-3059.
Arizona Surprise Billing Laws Take Effect January 1, 2019 Arizona's surprise billing laws impose new requirements for patient disclosure to prevent unexpected out-of-network bills, and, if necessary, a mandated dispute resolution process to compel parties to resolve payment disputes.
The debt dispute letter should include your personal identifying information; verification of the amount of debt owed; the name of the creditor for the debt; and a request the debt not be reported to credit reporting agencies until the matter is resolved or have it removed from the report, if it already has been
The new law, passed in late 2020, provides consumers with federal protection from unexpected out-of-network medical billsbills from healthcare providers who don't participate in the patient's health insurance network.
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