Patient letters
Pick the letter that fits, fill in the blanks, then copy or download it. Everything stays on your device — nothing you type is sent or saved. These are templates, not legal advice.
Not sure which letter you need? See the Patient Letter Hub. Appealing an insurance denial? Use the appeal letter builder. Asking for charity care? Use the financial assistance letter.
Itemized bill and billing records request
- Law:
- HIPAA right of access, 45 C.F.R. §164.524 (billing records are part of your record)
- Timing:
- The provider generally must respond within 30 days.
- Send to:
- The provider’s billing office or privacy officer.
Your letter
[Your name] [Your address] [Date] [Recipient name and address] Re: Request for itemized bill and billing records Account/Reference: [Account number] I request an itemized statement for services on [dates of service], showing each service, date, CPT/HCPCS or revenue code, units, and charge, along with all insurance payments, adjustments and the remaining balance. Under 45 C.F.R. §164.524, I also request a copy of the billing records for these dates. Please send them electronically or to the address above. Please place the account on hold, and do not send it to collections, while I review these records. Sincerely, [Your name]
Keep a copy and send by certified mail with return receipt when you can. Replace anything in [brackets] before sending.