Itemized bill request letter

When to use this letter

Use it when a bill shows only a total and you want the detail. You can request a list of the costs for each medical item or service you are being billed for^source. A note on wording: federal guidance describes this as something you can request, rather than a guaranteed entitlement. The one clear federal entitlement nearby is to a Good Faith Estimate of expected charges before a scheduled service if you are uninsured or self-pay^source.

The template

[Your name]
[Your address]
[City, State, ZIP]
[Date]

[Provider or billing office name]
[Billing office address]

Re: Request for itemized charges, account [account number], date of service [date]

To whom it may concern:

I am requesting a list of the costs for each medical item or service I am being billed for on the account referenced above. Please send an itemized statement that shows, for each item or service: the date, a description, any billing or procedure code, and the amount charged.

I would like this so I can compare the charges against my Explanation of Benefits before I pay. Please send the itemized statement to me in writing at the address above.

I can be reached at [phone] or [email].

Thank you,
[Your name]

How to use it

Replace every bracketed field and send the request in writing so you have a dated record. When the itemized statement arrives, put it next to your Explanation of Benefits and dispute anything that does not match using the medical bill dispute letter.