Out-of-Network / Balance Billing Dispute Letter

Build a letter disputing surprise billing or out-of-network charges with billed amounts, dispute reasons, and requested resolution.

Dispute balance billing / out-of-network charges

All fields are optional. Add billed amounts, dispute reason, and what you are requesting.

Status message placeholder

Policyholder Name

Address

Insurance Company

Policy Number

Member ID

Patient Name

Date(s) of Service

Provider / Facility

Bill Amount

Disputed Patient Responsibility Amount

Reason for Dispute

Request / Resolution Sought

Attachments Included

Creates a balance billing dispute letter with a resolution request and attachments block.

🔒 MANDATORY CODEX SAFETY FOOTER (INCLUDE VERBATIM)

Do not modify global layout, header, footer, ads, analytics, or shared components
Do not import @/components/ui/select or any unverified shadcn components
Use native HTML inputs only
Row add/remove buttons must be plain <button>
No date math, no parsing, no calculations
PDF builders must return Promise<Uint8Array>
Always create Blobs using bytesToPdfBlob(bytes) from lib/pdf/bytes.ts
Never include null in React-PDF style arrays
No refactors
Tool may only break itself

Processing stays in your browser. PDFs generate locally—no uploads or accounts.
Downloads use a secure PDF blob helper (no raw array buffers or workers required).
Review details before sending; nothing here is legal advice or a substitute for local forms.