ဆေးရုံစရိတ် အသေးစိတ်စာရင်း တောင်းခံစာ

Itemized hospital bill request — Ask the hospital for an itemized bill and a financial assistance form. Fill the blanks, then download the bilingual letter as a Word document.

Preview / အစမ်းကြည့်ရန်

______

To ______,

I received a bill for ______, account ______, for care on ______. I am requesting an itemized bill that lists each charge, and a financial assistance application. I would like to review the charges before I pay. Please pause collection on this account while my application is being reviewed.

Thank you,

______ — ______

______

______ သို့၊

______ တွင် ကုသမှုခံယူခဲ့သော ______ (အကောင့်နံပါတ် ______) အတွက် ငွေတောင်းခံလွှာ ရရှိပါသည်။ ကုန်ကျစရိတ် တစ်ခုချင်းစီ ဖော်ပြထားသော အသေးစိတ်ငွေတောင်းခံလွှာနှင့် ငွေကြေးအထောက်အပံ့ လျှောက်လွှာကို ပေးပို့ပါရန် တောင်းဆိုအပ်ပါသည်။ ငွေမပေးချေမီ စာရင်းကို စစ်ဆေးကြည့်ရှုလိုပါသည်။ လျှောက်လွှာကို စိစစ်နေသည့်ကာလအတွင်း ဤအကောင့်အတွက် ငွေတောင်းခံမှုကို ခေတ္တရပ်ဆိုင်းထားပေးပါရန် မေတ္တာရပ်ခံအပ်ပါသည်။

ကျေးဇူးတင်စွာဖြင့်၊

______ — ______

ငွေမပေးမီ အသေးစိတ်စာရင်း တောင်းပါ။ Ask for the itemized bill before you pay.

When to use this letter

Send this as soon as a hospital bill arrives, before paying anything. The first bill is normally a summary — one line, one large number — and it is not what you should pay from. An itemized bill lists every charge separately, which is the only way to spot a service you never received or one billed twice, and nonprofit hospitals keep a written financial assistance policy that can reduce or erase the balance for households on modest incomes.

How to send it

Ask for both things at once: the itemized bill and the financial assistance application. They come from the same office and asking twice adds weeks.
Send it before the due date, and keep paying any amount you have already agreed to — the request is not a reason to stop.
Apply for assistance even if you think you earn too much. The income limits are usually higher than families expect, and being uninsured is not a requirement.

Common mistakes

Paying the summary bill immediately to make it go away. Errors are common and a paid bill is much harder to get corrected.
Ignoring the bill instead. Silence is what sends an account to collections; a written request is what pauses it.
Missing the deadline for the assistance application — hospitals set their own, and it is usually counted from the date of service or the first bill.

If the letter is not enough

Some situations need a full document translated rather than a short letter — a handbook, a benefits notice, a form with tables and signature lines. Our free document translator keeps the original formatting intact, and the guides explain the processes behind most of these letters. If you are unsure which words mean what, the glossary explains them in Burmese.