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Request an itemized medical bill

Ask the provider for every charge, date of service, and procedure code before you pay or appeal.

Date:
Provider billing department:
Account or statement date (no member ID):
Service date (general):

Please send an itemized bill listing each charge, date of service, and procedure code. I am comparing this statement with the insurer Explanation of Benefits. Please hold collections while the itemized statement is prepared.

Mailing or portal address I can use:

Return to the related guide when you are ready for the next step.