No Surprises Act patient-provider dispute (uninsured/self-pay)

45 CFR 149.610 good-faith estimate; 149.620 dispute when billed >= $400 over the GFE, start within 120 days of the bill, $25 fee, no collections during the dispute

2026-11-10

To: [provider name]
Re: account [account number]
From: [Your name]

I received a good-faith estimate of [amount] and was billed [amount]. Under 45 CFR 149.620 I am starting the patient-provider dispute process at nsa-idr.cms.gov. Please do not send this bill to collection while the dispute is pending.

Please reply in writing.

[Your name]

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you.

Fill in the [brackets], sign, keep a copy, and send it yourself (certified mail for debt and credit letters).

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you. BillAdvocate is not a law firm and is not your lawyer: letters are drafted by software (and, only if you ask, reworded by an AI service) from what you enter, and no lawyer has reviewed them. Check every fact, amount and date before you send, and talk to a lawyer or legal aid office if you are being sued or a deadline is close. These letters are not a substitute for the advice of an attorney.