Letter of Complaint Bill Inquiry

XXX Hicks Street, Apt. #XA,

Bronx, NY 10469-1731

646.XXX.XXXX

Jane Doe

November 15, 2005

Manager, Out Patient Service

Montefiore Medical Group

111 East 210th Street

Bronx, NY 10467-2490

Subject: Bill Inquiry

Dear Sir or Madam:

On July 14, Dr. Rainone at the Williambridge, Montefiore Medical Center, saw me. This was just a general visited.

On August 28, I received a bill in the mail for service in the amount of $340.00. My first response was to call in to verify that the clinic had my current medial insurance on file. To my dismay the insurance on file was incorrect. I happily gave the representative by the name of, Marianne Clark, the correct insurance numbers and faxed in a copy of the card to be put on file. I was assured that everything was being taking care of. I was also told to disregard the notice and that a new charge will be sent out the correct insurer.

Since August 28, I am still receiving notices to pay the above amount. I am now being placed into collection. Just recently I was sent a letter from an attorney who has been assigned my claim. I am writing you in hope that this matter can be cleared up. I would like to be notified once this letter reaches you so we can go into great depth as how this can get resolve. I have enclosure copies of all documents so you may have in your possession, while we come to a discussion. Please feel free to contact me at the above contact information at anytime.

Thank you in advance.

Sincerely,

Jane Doe

Doe,Jane