Medical Bill Dispute Small Claims Form
Claimant Information
Full Name
Address
Phone Number
Email
Respondent (Medical Provider) Information
Provider/Facility Name
Address
Phone Number
Disputed Bill Information
Bill/Account Number
Date of Service
Amount Disputed
Reason for Dispute
Explain why you are disputing the medical bill
Attempts to Resolve
Describe any attempts to resolve this dispute directly with the provider
Supporting Documents
List any supporting documents you are submitting (e.g., bills, correspondence):
Declaration
I declare under penalty of perjury that the statements made in this form are true and correct to the best of my knowledge.
Signature
Date