Request for an itemized statement

Dear Patient Financial Services team,

I am asking for an itemized statement for each of these accounts: Maria Sample, account LDH-45821, services from July 14, 2026 to July 16, 2026.

Florida law says the hospital must provide it after discharge upon request, within 7 days of my request (Florida Statutes 395.301(1)(e)). Florida Statutes 395.301

Please send it to the address below. Thank you.

Sincerely,
Maria Sample
12 Example Lane
Riverton, ST 12345
(555) 010-0199

Signature

Where this comes from (for you, not part of the letter)

Florida Statutes 395.301, 2026, page 1: Upon request, and after the patient's discharge or release from a facility, the facility must provide to the patient or to the patient's survivor or legal guardian, as appropriate, an itemized statement or a bill detailing in plain language
Florida Statutes 395.301, 2026, page 1: The initial statement or bill shall be provided within 7 days after the patient's discharge or release or after a request for such statement or bill, whichever is later.

Rules: the public Financial Assistance Policy and form of Memorial Regional Hospital (FL; MHS = Memorial Healthcare System), applied to the fictional Lakeview Demo Hospital case.