[Your name]
[Your address]
November 7, 2026
Sample Family Clinic (synthetic)
[Provider address]
Request for an itemized bill and review of specific charges
Account number: [Account number]
Dear Billing Department,
I am writing to better understand the charges on my recent bill. Please send me a complete itemized bill that lists each service with its billing code, date, and charge. I would also appreciate a review of the items listed below, which I have questions about.
Items I would like reviewed
- 1.
71046: XRAY EXAM CHEST 2 VIEWS
Date of service: Sep 12, 2026 | Amount charged: $325.00
Amount in question: $287.22
Could you please tell me how this price was set? It may be well above what Medicare pays for the same service.
- 2.
No code listed: SUPPLIES / MISC
Date of service: no date listed | Amount charged: $35.00
Amount in question: $35.00
Could you please describe which service this charge covers? I could not tell from my bill.
I would be grateful for a written response within 30 days of receiving this letter. If any of these charges are correct, an explanation of the service and its billing code would be very helpful.
Thank you for your time and help.
Sincerely,
[Your name]
This letter was prepared with Unbundle and is not legal advice.