These are short, plain templates you can copy and adapt. Replace everything in [brackets], delete anything that does not apply, and keep a copy of whatever you send. A calm, specific request with documents attached usually gets further than a long complaint.
Before you use any of them: have your account number, the date of service, and your insurer’s Explanation of Benefits (EOB) in front of you. Write down the date, the name of each person you speak with, and any reference number.
1. Ask for an itemized bill
Use it when: you received a bill that shows only a total.
To: Billing Department, [Provider or hospital name]
Re: Account [number], date of service [date]
Please send me an itemized statement for this account that lists each charge separately with its date, description, billing code and amount, along with any insurance payments and adjustments already applied.
Please also note on my account that I have requested this statement and am reviewing the charges.
Thank you,
[Name, address, phone]
More detail: how to request an itemized hospital bill.
2. Question a charge or a bill that does not match your EOB
Use it when: the bill is higher than the patient responsibility on your EOB, or a line looks duplicated or wrong.
To: Billing Department, [Provider name]
Re: Account [number], date of service [date]
I am writing about the balance of $[amount] on this account. [Choose what applies:]
• My health plan’s Explanation of Benefits for this date of service shows patient responsibility of $[amount], which is different from your statement. A copy is enclosed.
• The itemized statement lists [describe the charge] [twice / for a service I do not believe I received]. Please review it against my records.
Please review the account, correct the statement if needed, and send me an updated bill. I would also ask that the account be placed on hold and not sent to collections while this review is open.
Thank you,
[Name, address, phone]
More detail: EOB vs. hospital bill and writing to a hospital patient advocate.
3. Ask about financial assistance
Use it when: the bill is correct but you cannot afford it.
To: Patient Financial Services, [Hospital name]
Re: Account [number], date of service [date]
I am not able to pay this balance in full. Please send me your financial assistance policy, the plain-language summary and the application form, and let me know which documents you need from me.
I also ask that collection activity on this account be paused while my application is being reviewed. If I do not qualify, please tell me about any discount or interest-free payment plan you offer.
Thank you,
[Name, address, phone]
More detail: hospital financial assistance and charity care.
4. Appeal a denied insurance claim
Use it when: your plan denied a claim or a prior authorization and you believe it should be covered. Check the denial letter for the deadline and the address.
To: Appeals Department, [Health plan name]
Re: Appeal of claim [number] / Member ID [number] / date of service [date]
I am appealing your decision dated [date] to deny [service or drug]. The reason given was: [copy the reason from the denial letter].
I believe this decision should be reversed because [state your reason briefly, for example: my doctor has documented that this treatment is medically necessary; the provider was in-network; the service is covered under section ___ of my plan].
Enclosed are: [the denial letter, a letter from my doctor, relevant records, the EOB]. Please review this appeal and send me your written decision. If you uphold the denial, please tell me how to request an external review.
Sincerely,
[Name, address, phone]
More detail: how to write a health insurance appeal letter.
5. Ask a debt collector to validate a medical debt
Use it when: a collection agency contacts you about a medical bill. Sending a written dispute within 30 days of the collector’s first notice gives you the strongest protection.
To: [Collection agency name]
Re: Your reference [number]
I dispute this debt and request validation. Please send me the name of the original creditor, the date of service, an itemization of the amount you say is owed, and documentation showing how the amount was calculated, including any insurance payments.
Please do not treat this letter as an acknowledgment that I owe this debt.
[Name, address]
More detail: dealing with medical debt collectors.
Three short phone scripts
To the billing office
“I’m calling about account [number]. Has this claim been processed by my insurance, and does this balance match my Explanation of Benefits? Could you send me an itemized statement and hold the account while I review it?”
To your insurer
“I’m calling about a claim for [date of service]. Is it finalized, pending or denied? Was the provider processed as in-network? What does my plan say I owe, and if it was denied, what is the deadline to appeal?”
Before a scheduled procedure
“Does this procedure need prior authorization under my plan? Has it been approved, and what is the authorization number? Will anyone involved, such as the anesthesiologist or the lab, bill separately?”
Good habits for any letter
- Send copies of documents, never originals.
- Stick to dates, amounts and what you are asking for.
- Use a method that gives you proof of delivery when the amount is large.
- Note the date you sent it and follow up if you hear nothing.
- Only state things that are true for your situation. Remove any line that does not apply.
General information only. These templates are educational examples, not legal advice, and they do not guarantee any result. Rules and deadlines vary by state and by plan. If you have been sued or served with court papers, contact a legal aid office or an attorney in your state. Official help: CMS, Medical bill rights and HealthCare.gov, How to appeal.