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Fill-in letters
Three letters people ask for most. Fill in the parts in [brackets], print the page or copy the words, and keep a copy for yourself.
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Ask for an itemized bill
Send this to the billing office before you pay a bill you can't check.
[Your name]
[Your address]
[Your phone or email]
[Date]
[Name of the hospital, practice or company]
Billing Department
[Their address]
Re: Request for an itemized bill
Patient: [name] · Account number: [number] · Date(s) of service: [dates]
Dear Billing Department,
I am writing to ask for a complete itemized bill for the account above. For each charge, please list the date of service, a description, the billing code (CPT, HCPCS or revenue code), the quantity and the price.
Please note on my account that I have asked for this bill, and let me know if anything is needed from me while I review it.
I am not refusing to pay. I am asking for a bill I can check.
Please send the itemized bill to [my address above / my email].
Thank you,
[Signature]
[Your name]
Ask for medical records
Send this to the medical records office (sometimes called Health Information Management).
[Your name]
[Your address]
[Your phone or email]
[Date]
[Name of the hospital, practice or company]
Medical Records Department
[Their address]
Re: Request for a copy of medical records
Patient: [name] · Date of birth: [date]
Dear Medical Records Department,
I am asking for a copy of [my / my mother's / my father's] medical records, under the patient's right of access in the HIPAA Privacy Rule (45 CFR 164.524).
Please send: [all records from (date) to (date) / visit notes / test results / imaging reports / billing records].
I would like the records [by email to (address) / through the patient portal / on paper, mailed to the address above].
If there is a fee, please tell me the amount before you send them, and the date I can expect them.
[For someone else's records: Their signed authorization is attached. / A copy of my healthcare power of attorney is attached.]
Thank you,
[Signature]
[Your name]
Ask for a payment plan
Send this to the billing office when you want to pay over time, directly with the hospital or practice.
[Your name]
[Your address]
[Your phone or email]
[Date]
[Name of the hospital, practice or company]
Billing Department
[Their address]
Re: Request for a payment plan
Patient: [name] · Account number: [number]
Dear Billing Department,
I am writing about the balance of $[amount] on the account above. I want to pay this bill, and I can pay $[amount] a month.
Please confirm in writing: the monthly amount, the number of payments, that no interest or fees will be added, and that the account will not be sent to collections while I keep to the plan.
Please also tell me whether I may qualify for your financial assistance policy, and send me the application.
Thank you,
[Signature]
[Your name]
Before you send it
- Keep a copy of the letter and anything you attach.
- Send it in a way you can prove: the patient portal, email, or mail with tracking.
- Write the date you sent it in your notes, and when you expect an answer.