Dunning Letter Template

{INSERT PICTURE LOGO OR HOSPITAL/CLINIC NAME}

{Address} · {City}, {State} {Zip Code} · P: {Phone} ∙ F: {Fax}

Encounter: {ENCOUNTER}
Date of Service: {DATE_SERVICE}
Balance: {Balance}
«Today’s_Date_Spelled_Out»

{GUAR_ADDRESS}
{GUAR_CITY}, {GUAR_STATE} {GUAR_ZIP_CODE}

Dear: {GUAR_FNAME} {GUAR_LNAME},

This is a reminder notice regarding your account, Encounter# {ENCOUNTER}, which is currently past due. You have yet to make any payment arrangements with us. We must, therefore, conclude that you do not intend to make a payment on this balance.

For information on how to apply for financial assistance, please contact our Business office at {PHONE}. Financial assistance applications may also be obtained from the Financial Assistance Policy section on our Hospital website at {WEBSITE}.

This bill may be referred to a collection agency 30 days from the date of this letter if no payment arrangements are made. Following placement with our designated collection agency, they may proceed with the following Extraordinary Collection Activities:

• Reporting of adverse information to consumer credit reporting agencies
• Civil action filing which could potentially lead to:
  • Garnishment of wages, bank accounts, or other personal property
  • Court Hearings
  • Judgement Liens
  • Other legal means of collection activity at the discretion of our designated collection agency

This can be avoided if you pay in full or contact us at {PHONE} within that time to make payment arrangements.

DIRECT PAYMENT TO:

CLINIC/HOSPITAL NAME

{ADDRESS}

{CITY}, {ST} {ZIP}

Sincerely,

{Client Contact}

{Client Contact Title}

{Clinic/Hospital Name}