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HIPAA Letter to
Collection Agency

HIPAA Letter to Collection Agency(2)

Use this letter to dispute the collection agency ability to collect on your account as they were informed information covered by HIPAA. This is a violation of your rights.

Date you will send this letter*
MM slash DD slash YYYY
Your Name*
First Middle Last Suffix
Your Address*
Street Address Address Line 2 City State ZIP Code
Name of Collection Agency*

Put the name of the collection agency
Address of Collection Agency*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Social Security Number*
Account number*
Amount you owe*

Put the amount your bill is for or the amount on your credit report.
Signature
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Phone
This field is for validation purposes and should be left unchanged.