LETTER TO COLLECTION AGENCY ON MEDICAL

ACCOUNT REPORTING WITH A BALANCE DUE

LETTER TO COLLECTION AGENCY ON MEDICAL
ACCOUNT REPORTING AS PAID
PLUS FOLLOW UP DISPUTE LETTER FOR
BOTH TO CRA
THIS IS ONLY TO BE USED WHEN THE HIPAA LETTER TO THE OC CAN
NOT BE IMMEDIATELY USED
COLLECTION AGENCY VALIDATION/DISPUTE/CEASE AND DESIST
Use this IN IT'S ENTIRETY. DO NOT call them .
Use this letter to oti!" the a#ec" that the $e%t is %e"o$ SOL& or is i'ali$ !or other
reasos& a$ s(%)ect to the *IPAA +ri'ac" la,s. -ee+ a co+" !or "o(r !iles a$ se$ the letter
certi!ie$ mail.EVEN IF YOU HAVE A STREET ADDRESS DO NOT USE THE RETURN
RECEIPT AS THE CAs ARE USING UPS DROP BOXES, SEND IT CERTIFIED ONLY AND
PRINT OUT THE ON LINE PROOF OF DELIVERY FOR THE FOLLOW UP LETTERDo
a se+arate letter !or EAC* CRA that the CA is re+orti# to& ma.e s(re the acco(t /'s match
the re+ort. Yo( ca 0AIL them all to each CA i ONE e'elo+e ,ith oe certi!ie$ mail /
Yo(r Name
123 Yo(r Street A$$ress
Yo(r Cit"& ST 41235
A6C Collectios
123 NotOYo(rLi!e A'e
Chica#o& IL
Date7 888888888 C0/888888888888
Re7 Acct / 9999:9999:9999:9999
To ;hom It 0a" Cocer7
This letter is %ei# set to "o( i res+ose to "o(r attache$ letter.
If you ha! "o#h$"% $" &'$#$"% us! #h! (h'as! )'!*!"# *o++u"$*a#$o", $f you ha!
ha, NO *o++u"$*a#$o" o#h!' #ha" #h! !"#'y o" you' '!(o'#, us! #h$s-
)Th$s .!##!' $s /!$"% s!"# #o you $" '!s(o"s! #o you' '!*!"# f'au,u.!"# !'$f$*a#$o" of
a" u"0"o&" +!,$*a. a**ou"# o" +y 1"a+! of CRA2 '!(o'#)
This is ot a re!(sal to +a"& %(t a otice that "o(r claim is $is+(te$.
U$er the <air De%t Collectios Practices Act =<DCPA>& I ha'e the ri#ht to re?(est 'ali$atio
o! the $e%t "o( sa" I o,e "o(. I am re?(esti# +roo! that I am i$ee$ the +art" "o( are
as.i# to +a" this $e%t&the $ate o! the alle#e$ me$ical ser'ice& the ame o! the +atiet a$
that there is some cotract(al o%li#atio ,hich is %i$i# o me to +a" this $e%t.
Please attach co+ies o!7
A#reemet ,ith "o(r cliet that #rats "o( the a(thorit" to collect o this alle#e$ $e%t&or
+roo! o! ac?(isitio %" +(rchase or assi#met. a$ a(thori@atio ($er s(%title D o! the
ARRA &SEC. 13541. APPLICATION O< SECURITY PROVISIONS AND PENALTIES TO 6USINESS
ASSOCIATES O< COVERED ENTITIESAa$ SEC. 1354B=1> 6REAC* O< SECURITY.CThe term
DD%reach o! sec(rit"EE meas& ,ith res+ect to (sec(re$ P*R i$eti!ia%le health i!ormatio o!
a i$i'i$(al i a +ersoal health recor$& ac?(isitio o! s(ch i!ormatio ,itho(t the
a(thori@atio o! the i$i'i$(al. Please ote that e!orcemet o! +ealties a#aist "o( is
co'ere$ ($er the +ealt" r(les o! the Omi%(s <ial R(le e!!ecti'e 4F/23/2413 iter+reti#
a$ im+lemeti# 'ario(s +ro'isios o! the *ealth I!ormatio Techolo#" !or Ecoomic a$
Cliical *ealth Act o! 244F =*ITEC* Act> as iss(e$ 11/34/244F a$ the +ealt" r(les o! the
<CRA a$ <ACTA icl($i# <ACT Act cha#es !ial r(les e!!ecti'e G(l" 1& 2414. .
A#reemet that %ears the si#at(re o! the alle#e$ $e%tor ,herei he or she a#ree$ to +a"
the cre$itor a$ as this is a me$ical acco(t a co+" o! a" *IPAA a(thori@atio.
Please also %e a$'ise$ that this letter is ot ol" a !ormal $is+(te& %(t a re?(est that "o(
cease a$ $esist a" a$ all collectio acti'ities& icl($i# re+orti# o!A or 'eri!"i# o! this
acco(t o m" cre$it re+orts.
Yo(r recei+t o! this letter ,ill %e cosi$ere$ as ha'i# #rate$ coset to the ta+i# o! a"
a$ all tele+hoe calls to me at m" home or %(siess %" "o( or "o(r a#ets or assi#s
I re?(ire com+liace ,ith the terms a$ co$itios o! this letter ,ithi 34 $a"s. or a
com+lete ,ith$ra,al& i ,riti#& o! a" claim.
I the e'et o! ocom+liace& I reser'e the ri#ht to !ile char#es a$/or com+laits ,ith the
OCR o "o(r *IPAA 'iolatios a$ a++ro+riate Co(t"& State H <e$eral a(thorities &the 666
a$ State 6ar associatios !or 'iolatios o! the <DCPA& <CRA& a$ <e$eral a$ State stat(tes
o !ra($(let eItortio a$ ille#al collectio acti'ities o a" acco(t that ma" %e time:
%arre$ as ,ell as i 'iolatio o! =ame o! "o(r State> me$ical +ri'ac" r(les.
I also here%" reser'e m" ri#ht to ta.e +ri'ate ci'il actio a#aist "o( to reco'er $ama#es.
Sicerel"&
Yo(r Name=PRINT OR TYPE DO NOT SIGN>
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Alternate Medical DV for accounts that have been PAIDTO THE REPORTING CA AND
ARE EING REPORTED A! "PAID CO##ECTION!"
= Yo( 0UST se$ the Jme$ical $is+(te letterJ <IRST a$ ha'e ha$ the acco(t 'eri!ie$> -ee+
a co+" !or "o(r !iles a$ se$ the letter certi!ie$ mail ., DO NOT USE THE RETURN
RECEIPT, EVEN IF YOU HAVE A STREET ADDRESS DO NOT USE THE RETURN
RECEIPT AS THE CAs ARE USING UPS DROP BOXES, SEND IT CERTIFIED ONLY AND
PRINT OUT THE ON LINE PROOF OF DELIVERY FOR THE FOLLOW UP LETTER
Do a s!(a'a#! .!##!' fo' EACH CRA #ha# #h! CA $s '!(o'#$"% #o, +a0! su'! #h!
a**ou"# 34s +a#*h #h! '!(o'#5 You *a" MAIL #h!+ a.. #o !a*h CA $" ONE !"!.o(!
&$#h o"! *!'#$f$!, +a$. 3Do a se+arate letter !or EAC* CRA that the CA is re+orti# to&
ma.e s(re the acco(t /'s match the re+ort. Yo( ca 0AIL them all to each CA i ONE
e'elo+e ,ith oe certi!ie$ mail/
Yo(r Name
123 Yo(r Street A$$ress
Yo(r Cit"& ST 41235
A6C Collectios
123 NotOYo(rLi!e A'e
Chica#o& IL
Date7 888888888 C0/888888888888
Re7 Acct / 9999:9999:9999:9999
To ;hom It 0a" Cocer7
This letter is %ei# set to "o( i res+ose to "o(r recet !ra($(let 'eri!icatio o! a
(.o, me$ical acco(t o m" =ame o! CRA> re+ortJ
This is a otice that "o(r re+orte$ claim is $is+(te$.
U$er the <air De%t Collectios Practices Act =<DCPA>& I ha'e the ri#ht to re?(est 'ali$atio
o! the $e%t . I am re?(esti# +roo! that I am i$ee$ the +art" "o( are re+orti# o this $e%t&
a$ there ,as some cotract(al o%li#atio ,hich ,as %i$i# o me to +a" this $e%t.
Please attach co+ies o!7
A#reemet ,ith "o(r cliet that #rate$ "o( the a(thorit" to collect o this alle#e$ $e%t&or
+roo! o! ac?(isitio %" +(rchase or assi#met. a$ a(thori@atio ($er s(%title D o! the
ARRA &SEC. 13541. APPLICATION O< SECURITY PROVISIONS AND PENALTIES TO 6USINESS
ASSOCIATES O< COVERED ENTITIESA a$ SEC. 1354B=1> 6REAC* O< SECURITY.CThe term
DD%reach o! sec(rit"EE meas& ,ith res+ect to (sec(re$ P*R i$eti!ia%le health i!ormatio o!
a i$i'i$(al i a +ersoal health recor$& ac?(isitio o! s(ch i!ormatio ,itho(t the
a(thori@atio o! the i$i'i$(al. Please ote that the e!!ecti'e e!orcemet o! +ealties a#aist
"o( is ($er the +ealt" r(les o! the Omi%(s <ial R(le e!!ecti'e 4F/23/2413 iter+reti#
a$ im+lemeti# 'ario(s +ro'isios o! the *ealth I!ormatio Techolo#" !or Ecoomic a$
Cliical *ealth Act o! 244F =*ITEC* Act> as iss(e$ 11/34/244F
A#reemet that %ears the si#at(re o! the alle#e$ $e%tor ,herei he or she a#ree$ to +a"
the cre$itor a$ as this is a me$ical acco(t a co+" o! a" *IPAA a(thori@atio.
Please also %e a$'ise$ that this letter is ot ol" a !ormal $is+(te& %(t a re?(est that "o(
cease a$ $esist a" a$ all re+orti# acti'ities.
Yo(r recei+t o! this letter ,ill %e cosi$ere$ as ha'i# #rate$ coset to the ta+i# o! a"
a$ all tele+hoe calls to me at m" home or %(siess %" "o( or "o(r a#ets or assi#s
I re?(ire com+liace ,ith the terms a$ co$itios o! this letter ,ithi 34 $a"s. a$ a
com+lete ,ith$ra,al& i ,riti#& o! a" re+ort to a" cre$it re+orti# a#ec". I the e'et o!
ocom+liace& I reser'e the ri#ht to !ile char#es a$/or com+laits ,ith the OCR o *IPAA
'iolatios a$ a++ro+riate Co(t"& State H <e$eral a(thorities &the 666 a$ State 6ar
associatios !or 'iolatios o! the <DCPA& <CRA& a$ <e$eral a$ State stat(tes !or !ra($(let
sla$er o! cre$it a$ ille#al re+orti# acti'ities o a acco(t that is time:%arre$ as ,ell as
=ame o! "o(r State> me$ical +ri'ac" r(les.
I also here%" reser'e m" ri#ht to ta.e +ri'ate ci'il actio a#aist "o( to reco'er $ama#es.
Sicerel"&
Yo(r Name=PRINT OR TYPE DO NOT SIGN>
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$O##O% &P #ETTER TO CRA !END CM DO NOT &!E THE RET&RN RECEIPT
Dear CRA&
0" ame is IIIII IIIIII & m" SS / is III II IIII.
I am se$i# this $is+(te certi!ie$ mail recei+t / IIII to ma.e s(re "o( recei'e it.
I ha'e o .o,le$#e or recor$s o! acco(t / IIIII o m" re+ort / IIIII.
I ha'e $is+(te$ this (.o, me$ical acco(t ,ith the re+orti# Collectio A#et&= co+"
eclose$ ,ith +roo! o! their recei+t>&as +er "o(r istr(ctios i "o(r res+ose o! II/II/IIII
to m" $is+(te o! II/II/IIII a$ ha'e ha$ o 'ali$ res+ose.
Please a$'ise me as to the ame a$ a$$ress o! the health care +ro'i$er& the ame o! the
+atiet& a$ the re+orte$ $ate o! ser'ice&as a" acco(t I mi#ht ha'e ha$ at oe time ,o(l$
%e o%solete.
I! "o( ca o%tai this i!ormatio& I also ,o(l$ ee$ the ame o! the +erso +ro'i$i# this
$ata& a$ the maer i ,hich it ,as +ro'i$e$ i or$er that I ma" +(rs(e a$$itioal le#al
reme$ies.
I! "o( are (a%le to 'eri!" a$ re!(se to $elete& I ,ill %e !ili# a++ro+riate com+laits a#aist
"o( ,ith the <TC !or <CRA a$ <ACTA 'iolatios&the OCR !or *IPAA 'iolatios a$ a++ro+riate
State a(thorities.
Please ote that as a reci+iet o! +ri'ate me$ical $ata "o( are also s(%)ect to the +ro'isios
o! s(%title D o! the ARRA &SEC. 1354B=1> 6REAC* O< SECURITY.CThe term DD%reach o!
sec(rit"EE meas& ,ith res+ect to (sec(re$ P*R i$eti!ia%le health i!ormatio o! a
i$i'i$(al i a +ersoal health recor$& ac?(isitio o! s(ch i!ormatio ,itho(t the
a(thori@atio o! the i$i'i$(al. Please ote that the e!!ecti'e e!orcemet o! +ealties a#aist
"o( !or this %reach is ($er the +ealt" r(les o! the Omi%(s <ial R(le e!!ecti'e 4F/23/2413
iter+reti# a$ im+lemeti# 'ario(s +ro'isios o! the *ealth I!ormatio Techolo#" !or
Ecoomic a$ Cliical *ealth Act o! 244F =*ITEC* Act> as iss(e$ 11/34/244F .
A$$itioall" "o(r Cre$it Re+orti# A#ec" is o, s(%)ect to <e$eral cos(mer !iacial la,s&
icl($i#& amo# others& the <CRA a$ Title 9 o! the Do$$:<ra. Act& a$ relate$ re#(latios
icl($i# a %a o KA%(si'eL Acts or Practices. = Sectio 1431 o! the Do$$:<ra. Act >
.
I also reser'e the ri#ht to icl($e "o(r 6(rea( i a" le#al reme$ies I +(rs(e.
Ver" tr(l" "o(rs&
IIIIII
Why Cha#4s C'!,$# Co"fus$