SAMPLE - FICTIONAL DATA

October 27, 2026

Patient Financial Services, Lakeview Demo Hospital

Subject: 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)).

Please send it to the address below. Thank you.

Sincerely,

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