Your itemized bill request

A polite letter asking the billing office for a fully itemized bill and its financial assistance policy. It works for any bill, even one with no flagged items.

Your details

Fill these in to complete the letter. Nothing you type here is saved or sent anywhere. It stays in this browser tab.

Your name

Your address

Account number

Provider or billing office name

Provider address

Letter date

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Read the letter and check each item against your bill before you send it.

[Your name]

[Your address]

November 7, 2026

Sample Family Clinic (synthetic)

[Provider address]

Request for an itemized bill and financial assistance policy

Account number: [Account number]

Dear Billing Department,

I am writing about my account with your facility. Please send me the following in writing so that I can review my charges.

What I am requesting

1.
A fully itemized statement that lists every service and supply with its CPT or HCPCS billing code, date of service, number of units, and charge.
2.
A copy of your financial assistance (charity care) policy, along with the application and any plain-language summary you provide.

I would be grateful for a written response within 30 days of receiving this letter. Thank you for your help in making my bill clear.

Thank you for your time and help.

Sincerely,

[Your name]

This letter was prepared with Unbundle and is not legal advice.

Next step (optional): financial help

See whether you might qualify for the hospital's financial assistance program.

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