免费指南
填空信函
最常用的三封信。填好 [方括号] 里的内容，打印本页或复制文字，并给自己留一份副本。
照片：Kampus Production / Pexels
索取明细账单
在支付一张您无法核对的账单之前，把这封信寄给账单部门。
[您的姓名]
[您的地址]
[您的电话或电子邮箱]
[日期]
[医院、诊所或公司名称]
Billing Department（账单部）
[对方地址]
事由：申请明细账单 [Re: Request for an itemized bill]
患者 Patient：[姓名] · 账号 Account number：[号码] · 服务日期 Date(s) of service：[日期]
尊敬的账单部：[Dear Billing Department,]
我写信是想索取上述账户的完整明细账单。请为每一项收费列出服务日期、说明、计费代码（CPT、HCPCS 或收入代码 revenue code）、数量和价格。[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.]
请在我的账户上注明我已申请这份账单，并告诉我在我核对期间是否需要我提供什么。[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.]
我并不是拒绝付款。我只是想要一份我能核对的账单。[I am not refusing to pay. I am asking for a bill I can check.]
请把明细账单寄到 [我上面的地址 / 我的电子邮箱]。[Please send the itemized bill to (my address above / my email).]
谢谢！[Thank you,]
[签名]
[您的姓名]
索取病历
把这封信寄给病历部门（有时叫 Health Information Management，健康信息管理部）。
[您的姓名]
[您的地址]
[您的电话或电子邮箱]
[日期]
[医院、诊所或公司名称]
Medical Records Department（病历部）
[对方地址]
事由：申请病历副本 [Re: Request for a copy of medical records]
患者 Patient：[姓名] · 出生日期 Date of birth：[日期]
尊敬的病历部：[Dear Medical Records Department,]
根据 HIPAA 隐私规则（HIPAA Privacy Rule，45 CFR 164.524）赋予患者的查阅权，我申请一份 [我的 / 我母亲的 / 我父亲的] 病历副本。[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).]
请寄送：[（日期）至（日期）的全部病历 / 就诊记录 / 检查结果 / 影像报告 / 账单记录]。[Please send: (all records from (date) to (date) / visit notes / test results / imaging reports / billing records).]
我希望以 [电子邮件发送至（地址）/ 通过患者门户网站 / 纸质版邮寄到上面的地址] 的方式收到病历。[I would like the records (by email to (address) / through the patient portal / on paper, mailed to the address above).]
如果需要收费，请在寄出前告诉我金额，以及我预计哪一天能收到。[If there is a fee, please tell me the amount before you send them, and the date I can expect them.]
[如果是他人的病历：附上本人签署的授权书。/ 附上我的医疗委托书副本。] [(For someone else's records: Their signed authorization is attached. / A copy of my healthcare power of attorney is attached.)]
谢谢！[Thank you,]
[签名]
[您的姓名]
申请分期付款
想直接和医院或诊所分期付款时，把这封信寄给账单部门。
[您的姓名]
[您的地址]
[您的电话或电子邮箱]
[日期]
[医院、诊所或公司名称]
Billing Department（账单部）
[对方地址]
事由：申请分期付款 [Re: Request for a payment plan]
患者 Patient：[姓名] · 账号 Account number：[号码]
尊敬的账单部：[Dear Billing Department,]
我写信是关于上述账户 $[金额] 的欠款。我愿意支付这笔账单，我每月可以付 $[金额]。[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.]
请书面确认：每月金额、付款次数、不会另加利息或费用，以及只要我按计划付款，账户就不会被转交催收机构。[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.]
也请告诉我是否可能符合你们财务援助政策（financial assistance policy）的条件，并把申请表寄给我。[Please also tell me whether I may qualify for your financial assistance policy, and send me the application.]
谢谢！[Thank you,]
[签名]
[您的姓名]
寄出之前
- 信和所有附件都留一份副本。
- 用能留下凭证的方式寄出：患者门户网站、电子邮件，或可追踪的邮寄。
- 在笔记里写下寄出日期，以及预计什么时候能收到答复。