How to request an itemized medical bill

[Your name]
[Your mailing address]

[Today's date]

[Billing office name]
[Billing office address]

Re: Request for an itemized bill. Patient: [Patient name]. Account: [Account number]. Date of service: [Date of service].

To the billing office:

I received a bill for [amount] for the care listed above. Please send me a complete itemized bill that shows, for each charge:

• the date of the service;
• a description of the service, supply or drug;
• its billing code (CPT, HCPCS or revenue code) and the quantity;
• the amount charged;
• every payment, insurance payment and adjustment applied to the account.

Please also tell me whether any discount or financial assistance policy applies to this account, and send me a copy of it.

While I review the itemized bill, please do not send this account to a collection agency. Please send the itemized bill to the address above.

Thank you,

[Your name]