Free compliance & forms tool
Chargeback Response Letter Template for Aesthetic Practices
A chargeback response is a short, factual letter to the card issuer, sent through your payment processor, that answers the cardholder's specific claim and points to enclosed evidence: the receipt, the appointment record, the signed policy or consent, and your messages with the patient. Pick the claim below, tick the evidence you have, and the letter writes itself. Send it before your processor's deadline; Stripe, for example, allows one submission.
Prepared by Prospyr · Reviewed October 28, 2026 · Free, no sign-up, runs in your browser
Name and phone or email.
From your processor's dispute notice.
Never the full card number.
For example: one neuromodulator appointment. Leave out clinical detail.
Match the reason on your processor's notice.
Facts only: dates, what was said, what you offered. No clinical detail the dispute does not need.
Everything you type stays in your browser. Nothing is sent, saved or added to the page address, and it clears when you close or reload the page. Copy or print before you leave.
Your response letter
Chargeback response: [Practice name]
Case or dispute number: [case number]. Transaction date: [transaction date]. Amount: [amount].
We ask that this dispute be reversed in our favor for the reasons below.
The cardholder states the service was not as described. [patient name as on the receipt] received [service, in billing terms] on [date of service], the service that was booked, described before treatment and agreed to in writing. Our refund policy, which the patient acknowledged, explains how concerns about a completed service are handled.
Enclosed: 1. Itemized receipt for the charge
We have limited the patient information in this response to what the dispute requires.
[Practice name]
A starting draft, not legal advice. Check your processor's deadline and upload rules before you send it, and share only the patient information the dispute needs.
Disputes over no-show fees? See deposits collected at booking and no-show fees charged to the card on file →
How to use the template
- Read the dispute notice. Note the reason, the deadline and the case number. Choose the matching claim in the form.
- Gather the evidence that answers that claim. The checklist marks which items fit. Tick only what you actually have.
- Describe the service in billing terms. “One neuromodulator appointment” proves the visit; treatment notes and photos usually are not needed.
- Copy the letter into your processor's dispute form or print it to PDF and upload it with the enclosures, combined in the order listed.
- Consider whether to accept instead. If the patient has a fair point, a refund and a conversation may cost less than a lost dispute and its fees.
Prevent the next one
Build the evidence before a dispute arrives. Show your cancellation policy before a card is taken, keep the signed acknowledgment, send booking confirmations and reminders, and use a billing descriptor patients will recognize on their statement. Run the cost of missed visits through the no-show cost calculator, and compare processor rates with the credit card processing fee calculator.
Frequently asked questions
How long do I have to respond to a chargeback?
Your processor sets the deadline in its dispute notice, based on the card network's rules. Stripe says the window is usually 7 to 21 days depending on the card network, and that a dispute with no response before the deadline is lost automatically. Check the date on your own notice the day it arrives.
Can I send more evidence later?
Often not. Stripe, for example, says you have one opportunity to submit, and you cannot edit the response or add files afterward. Assemble everything before you send, and check your own processor's rules.
What evidence wins a med spa chargeback?
Evidence that answers the specific claim. For “not authorized”, show the patient was there: check-in record, signed consent page, ID check, earlier visits on the same card. For “not as described”, show what was agreed: the consent signature page and your refund policy. For a no-show fee, show the signed policy and the reminders sent. A receipt alone rarely answers the claim.
Can I send the patient's chart or photos to the bank?
Send only what the dispute needs. HIPAA's minimum necessary standard asks you to limit protected health information to the minimum needed for the purpose. A consent signature page and an appointment record usually prove the visit without clinical notes or photos. Ask your privacy officer or attorney before sending more.
Can I include links or a video in my response?
Check your processor's rules. Stripe says the banks reviewing disputes will not review external content, so it tells merchants not to include audio or video files, links, or requests to call or email for more information.
How long does a cardholder have to dispute a charge?
That depends on the card network's rules and the type of claim, and your processor's notice is the source for your case. Separately, under Regulation Z a credit card holder can raise a billing error, including services not accepted or not delivered as agreed, by written notice the issuer receives within 60 days after it sent the first statement showing the charge.
Is my text saved or sent anywhere?
No. What you type stays in your browser. It is not sent to Prospyr, not saved and not added to the page address, and it clears when you reload. Copy or print the letter first.
Sources and scope
- Stripe Docs: Respond to disputes
Response window usually 7 to 21 days depending on the card network; no response means the dispute is lost; one submission that cannot be edited; banks will not review audio, video or links.
- 12 CFR 1026.13 (Regulation Z): Billing error resolution
Billing errors include property or services not accepted or not delivered as agreed; notice must be received within 60 days after the first statement showing the error.
- 45 CFR 164.502(b): Minimum necessary standard
Covered entities must make reasonable efforts to limit protected health information to the minimum necessary for the purpose.
A starting draft, not legal advice. Deadlines, reason codes and evidence rules come from your processor and the card networks and change over time; check your dispute notice. Share only the patient information the dispute requires.