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Dispute Amount Adjusted

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Description

Used in select letters when the dispute amount is being adjusted.

Content

Date

Description

Amount

Original Dispute Amount

New Dispute Amount

<Date>

<Descriptor>

<Amount>

<Disputed Amount>

<Amount>

We have determined that the amount of the dispute was incorrect and have adjusted it as shown above.

Sample

Date

Description

Amount

Original Dispute Amount

New Dispute Amount

06/25/2024

http://WWW.CAREMARK.COM 888-892-7227 IL

$397.00

$397.00

$597.00

We have determined that the amount of the dispute was incorrect and have adjusted it as shown above.

Rule

N/A

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