SAMPLE - FICTIONAL DATA

March 2, 2026

Billing office, Brightwater Healthcorp Inc

Subject: Billing dispute: the same service billed twice

Dear Brightwater Healthcorp Inc billing team,

My statement for account 44932556 lists the same service twice: lines 1 and 2, code 01960, on February 11, 2025, $4,944.00 each. Please remove the duplicate and my $196.82 share of it, as my insurance statement shows.

Please correct the balance, or explain it in writing. Please answer in writing within 30 days.

Attached: Copy of the Explanation of Benefits

Sincerely,

Daniela Castillo
9349 Seagrape Ln Apt 717
Bayside, FL 33067
(954) 555-0161