SAMPLE - FICTIONAL DATA

March 2, 2026

Patient Financial Services, Seaside Regional Hospital

Subject: Request for an itemized statement

Dear Patient Financial Services team,

I am asking for an itemized statement for each of these accounts: Daniela Castillo, account 5057388228, services from February 11, 2025 to February 13, 2025; Daniela Castillo, account 5057388214, services from February 11, 2025 to February 13, 2025.

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,

Daniela Castillo
9349 Seagrape Ln Apt 717
Bayside, FL 33067
(954) 555-0161