Educational only, not legal or financial advice; not affiliated with any hospital or insurer.

Itemized bill request letter

Fill in what you know, press Make my letter, then copy, print, download or email it yourself. Everything runs in your browser. We don't receive, save or store anything you type. This page does not use browser storage. To compare bill lines on this device, use Check a bill.

Tip: send it to the billing office address or email printed on your statement, and keep a copy with the date you sent it.

You Your full name (required) Your mailing address Your email or phone (optional) Patient name, if it's not you (optional)

For a child or someone you're authorized to act for.

The bill Billing office or provider name (required)

As it appears on the statement, for example "Patient Financial Services, Example Medical Center".

Billing office address (optional) Account or statement number (optional) Date(s) of service (optional)

Copy it from the statement.

Insurance claim number (optional)

It's on your EOB. Leave blank if you don't have one.

Also ask for A record of all payments, insurance payments and adjustments A note that the balance is under review, and whether collections can pause while I review The financial assistance (charity care) policy and application, prompt-pay discount and payment plan options Mention my HIPAA right to access billing records

Under the HIPAA Privacy Rule, billing records are part of the "designated record set" patients can access (HHS guidance). Optional; the request works without it.

Next: compare it with your EOB

When the itemized bill arrives, use the EOB checklist to match it against what your insurer says.

Itemized bill request letter

Your letter

Next: compare it with your EOB