Draft a letter to your Insurance Company

To whom it may concern at  

I am writing to you in regards to a medical bill that I received for charges rendered on March 2, 2016 for the total amount of $. I have reviewed both the procedure codes and charges and it has come to my attention that there are errors in this statement. I am requesting that these error(s) be corrected in a timely manner. Upon doing so, please send a corrected statement to me and I will review the amended bill. Please find the necessary details below.

Personal Health Insurance Information*
Date of birth: // Health insurance provider: Plan name:
Group name: Subscriber #: Group #:

* Missing some information? Please update your profile.

Action requested:

Thank you in advance for your prompt attention to this matter.
Please find documents attached supporting my position.