Medical Collection Dispute Letter to Collection Agency Please enter your full name.* Please enter your current address. Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Which credit bureau are you trying to contact? * TransUnion Experian Equifax Please enter the name of the healthcare provider that originally owned your medical debt.* Please enter the account number associated with the medical debt, collection agency, or healthcare provider.* When was your medical collections account opened?* When were you billed for the medical services that were sent to a collection agency?* How much medical debt is owed on this collection account?* Please thoroughly describe which information is inaccurate or incomplete or why it should be deleted (e.g., the medical bill was paid by insurance or is more than 7 years old).* Please list any supporting documents you will send along with this medical collection dispute letter.* Please enter today’s date.* Your Email Address*
