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[Your Name] [Your Address] [Phone or Email] [Today's Date] Billing Department Riverside Medical Center [Provider Address] Re: Account number [Account Number], date of service [Date of Service], patient [Patient Name] To whom it may concern, I am writing regarding the bill referenced above, which totals $4,200 for an emergency room visit. I would like to resolve this account, and I am asking you to review the following before any further collection activity. First, please send me a fully itemized bill, with each charge listed separately and its CPT or HCPCS billing code included. The statement I received shows only summary totals, which I cannot properly review. On the summary I did receive, one charge appears to be listed twice. Please review the account for any duplicate charges and correct them. I am an uninsured, self-pay patient. I am requesting that these charges be reduced to your self-pay or prompt-pay rate, which I understand is often substantially lower than the amount first billed. Paying this bill in full would be a significant financial hardship for my household. [One sentence about your situation, for example: I am the sole earner supporting two children.] With that in mind, I am asking that we agree on either a reduced balance I can pay or an interest-free monthly payment plan at an amount I can realistically afford. While this account is under review, please place it on hold and keep it out of collections, and please confirm in writing that you have done so. I would appreciate a written response within 30 days. I can be reached at [Phone or Email]. Thank you for your time and help. Sincerely, [Your Name]