Itemized bill request

[DATE]

[HOSPITAL OR PROVIDER NAME]

Attn: Patient Billing

[ADDRESS]

Re: Request for itemized statement

Patient: [PATIENT NAME], DOB [DOB]

Account number: [ACCOUNT NUMBER]

Date(s) of service: [DATES]

To whom it may concern,

Please send me a fully itemized statement for the account above, including:

- Every line item charge with its date, description, quantity, and unit price

- The CPT, HCPCS, and revenue codes billed for each item

- The ICD-10 diagnosis codes submitted

- Any payments, adjustments, or insurance write-offs already applied

I am reviewing this account for accuracy before payment. Please place any collections activity on hold until I have received and reviewed the itemized statement.

Please also send me a copy of your Financial Assistance Policy and plain language summary.

You can reach me at [PHONE] or [EMAIL].

Sincerely,

[YOUR NAME]

[MAILING ADDRESS]