Request an itemized bill

Create a precise request for the codes, units, providers, adjustments, and totals needed to review every charge.

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Your request

[Provider or facility] — Billing Department

Request for a complete, itemized bill

To Whom It May Concern,

Please send me a complete, line-by-line bill for the account and dates listed above. A balance summary is not enough for me to review the charges.

For every billed line, please include the following when it exists in your billing record:
- Date of service
- Original billing code exactly as submitted, plus the code system or type (for example CPT, HCPCS, revenue code, NDC, DRG, or another code set)
- Every modifier attached to the code
- Printed service, supply, drug, room, or facility description
- Quantity or units and any per-unit charge
- Line charge before payments, adjustments, or credits
- Billing provider, rendering provider, and facility identity associated with the line

For the bill or claim as a whole, please also include the following when available:
- Total charges before insurance
- Each insurer payment, patient payment, contractual adjustment, discount, credit, and other adjustment
- Insurer allowed amount and patient responsibility, clearly labeled rather than combined
- Claim, account, or control numbers needed to match this bill to an EOB
- Denial, adjustment, CARC, or RARC codes and their explanations

If a requested field does not exist or is unavailable, please identify that instead of assigning or guessing a value. In particular, please do not assign a CPT or HCPCS code to a line that was billed only under another code system.

Please send the itemized bill and any available code or adjustment key using the delivery method I specify to your office.

Thank you,
[Your name]

Review the letter before sending it. The template requests available records; it does not promise that every field is available or set a legal response deadline.