Request for an itemized bill

Here is a letter asking for an itemized bill with codes and prices, and a hold on collections while you review it. Fill in the bracketed parts and send it yourself.

Start here: an itemized bill lists every code, unit and price, so you can check each line. · Checked 28 September 2026

The letter

This is the draft Med Bill Check writes. On the home page you can add your details and, for a review letter, the code and amount, and it fills them in. Anything in [brackets] is for you to complete.

[Your full name]
[Your address]
[Your phone or email]
[Today's date]

Billing Department
[Provider or hospital name]
[Provider address]

Re: Account number [account number], date of service [date of service], patient [patient name]

Dear Billing Department,

Please send me a fully itemized bill for the account above. For each charge, please include the date, a plain description, the billing code (CPT, HCPCS or revenue code), the number of units and the price. If insurance was billed, please also show what was billed, what was paid and any adjustments.

Please also send a copy of my billing records for this account. Billing records are part of the records patients can request under HIPAA.

While I review the itemized bill, please put the account on hold and do not send it to collections.

Thank you for your help. I look forward to hearing from you.

Sincerely,
[Your name]

Tips

• Compare every line with your Explanation of Benefits if you have insurance.
• Look for duplicate lines, services you did not receive, and unit counts that look high.
• Use /v1/price to check any code against Medicare rates.

Your rights

• No Surprises Act. Since 2022, most people with health insurance are protected from surprise bills for most emergency care, for out-of-network providers at in-network hospitals and surgery centers, and for air ambulances. You should only owe your in-network cost sharing. Official page
• Good Faith Estimate. If you are uninsured or not using insurance, providers must usually give you a Good Faith Estimate when you book care at least 3 business days ahead, or when you ask for one. Official page
• Bill above your estimate. If a provider bills at least $400 more than its Good Faith Estimate, you may be able to use the federal patient-provider dispute process. Start within 120 calendar days of the date on the bill. The fee is $25. Official page
• Free help. The No Surprises Help Desk answers questions about these rights on 1-800-985-3059. Official page

Other letters

• Request to review a charge
• Request for a prompt-pay or self-pay discount
• Request for financial assistance (charity care)

Sources

• https://www.cms.gov/nosurprises
• https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6
• https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency

This is a draft for you to review, edit and send yourself. It is general information, not legal, medical or financial advice. Med Bill Check never sends anything for you.