Medical Collection Dispute Letter to Credit Bureau 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 Please enter your date of birth.* Please enter your home or mobile telephone number.* Which credit bureau are you trying to contact?* TransUnion Experian Equifax Please select the address associated with the credit bureau you would like to contact.* TransUnion Consumer Solutions, P.O. Box 2000, Chester, PA 19016 Experian, P.O. Box 4500, Allen, TX 75013 Equifax Information Services, LLC, P.O. Box 740256, Atlanta, GA 30374 What is your credit report number?* What is the Social Security number associated with your account? (This information will not be stored or shared by FinanceJar.) What is your driver’s license number or ID number? (This information will not be stored or shared by FinanceJar.) Please enter the name of the healthcare provider that originally owned your medical debt.* What is the name of the debt collector or agency that has contacted you?* 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 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*
