SAMPLE - FICTIONAL DATA

April 21, 2025

Patient Financial Services, Seaside Regional Hospital

Subject: Request for an itemized statement

I am asking for an itemized statement for each of these accounts: Daniela Castillo, account 4788416; Daniela Castillo, account 44932556, services on February 11, 2025; Daniela Castillo, account 30955, services November 25, 2024 to January 6, 2025; Daniela Castillo, account 409798605, services February 11, 2025 to February 13, 2025; Daniela Castillo, account 5057388214; Adrian James Castillo, account 5057388228.

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