Letter asking for an itemized bill

An itemized bill lists every charge. Fill in the form and download a letter you can send.

An itemized bill lists every charge. Fill in the form and download a letter you can send.

Date of the letter (required)

Your state (required)

Your full name (required)

Your mailing address (required)

Where the reply should be sent.

Your email or phone (optional)

Hospital or provider name (required)

How will you send it?

Their mailing address (required)

Required when you mail it. The bill or the website lists it.

Account or patient number (optional)

Date or dates of the care (optional)

Medicare paid for part of this careAsk them to hold the account (no collection steps) while they answer

Anything else to add (optional, in English)

It goes into the letter as you type it.

Other formats

Sign the letter, keep a copy and keep proof of how and when you sent it (certified mail with a return receipt is one way).

Federal rules for nonprofit hospitals apply in every state. Free help can review your bill.