Request for Itemized Bill

SAMPLE — not a real letter. Names, amounts, and account numbers are fictional.

April 20, 2026 Jordan Sample 123 Sample Street Anytown, ST 00000 Northbridge Health System Patient Financial Services 400 Example Avenue Anytown, ST 00000 RE: Request for itemized statement — Account ACCT-0000-SAMPLE, date of service March 14, 2026 To whom it may concern: I received a statement dated April 8, 2026 for my emergency department visit on March 14, 2026. The statement shows a single line, "Emergency services," in the amount of $4,862.00, with no breakdown of what that figure covers. I am writing to request a complete itemized statement before I make any payment decision. Please send an itemization that lists every charge separately, including for each line: the date of service, the CPT or HCPCS code and its plain-language description, the quantity, the individual charge, the name of the provider or department that delivered the service, and any insurance payments, contractual adjustments, or discounts applied to the account. If any charge was billed by a separate professional group (for example, emergency physicians or radiology), please identify that group and the amount it billed. While I review the itemization, I ask that you place this account on hold, apply no late fees or interest, and refrain from referring it to any collection agency. I am not refusing to pay a correct balance; I am asking to see what I am being asked to pay for before I pay it. I would appreciate receiving the itemized statement within 30 days of the date of this letter. If I have not received it by May 25, 2026, I will follow up in writing. Please send all correspondence to the address above rather than contacting me by phone, so that I have a written record. Thank you for your attention to this request. Sincerely, Jordan Sample Enclosures: Copy of statement dated April 8, 2026