November 23, 2017
 
Provider Negotiation

 
Your Name and Address
 
Date 
 
Medical Provider’s Address 
 
Dear Dr _________:
I am writing to you in regards to a bill I received in the amount of [Dollar Total] for a medical service I received on [Date]. 
 
As I do not have a health plan I am requesting a substantial discount on the amount currently owed to you.  I am willing to pay $__________ in ____ monthly payments of $_______.   I realize that individuals who have health insurance are not expected to pay the full balance, as their health plan will pay a negotiated fee or will apply their Usual and Customary Reduction on the balance owed.  These discounts off of your balance can be as much as 80%.
 
I have also performed some additional research on Cash Pay Patients who have balances due with their physicians, and a standard Cash Pay Discounts can range between 60 to 80%.  I am requesting a discount of ___%.  I believe this is a fair amount to pay.
 
Please honor my discount request and contact me at your earliest convenience or sign this document below if you agree to accept this negotiated fee. If I do not hear from you within 30 days, I will contact you again.  Please do not initiate any collections activity until you have contacted me directly as I fully intend to pay what is fair and appropriate and would like to work out a payment arrangement with you.  
 
Thank you for your time and assistance in this matter.
 
Sincerely,
 [Patient Name]
 
I agree to pay the total amount of $________ in ___ monthly payments of $_____.
Patient Signature: _________________________________ Date:___________
We agree to accept this payment arrangement:
Provider’s Signature:______________________________ Date:___________