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DOCUMENT OVERVIEW : This document may used to negotiate patient balances prior to forwarding to collections or legal counsel .

[date]

[inside address]

Dear [name]:

Our attempts to collect your debt of [$—] have brought no response. Your account is scheduled to be turned over to our legal councel in [—] days.

We are willing to settle the disputed account [$—]. By paying [$—] within [—] days of receipt of this letter, you will avoid legal action and the possiblity of credit rating impairment. A preaddressed stamped envelope is enclosed.

Yours truly,

[name]

Enclosure

This document is provided to you as a courtesy by PGM Billing, a full service medical billing company.

This document is free to use it for personal or office use; however, may not be reproduced, transferred, sold, used for financial gain, or circulated in the public domain, without prior written authorization from

PGM Billing. !