The Manager,
___________ (Name of the Hospital),
___________ (Address)

Date: __/__/____ (Date)

Subject: Application for refund of _________ (refund details)

Respected Sir/Madam,

I am _________ (Name) and I am a resident of __________ (Address).

I got admitted in your hospital on __/__/____ for _______ (treatment name) treatment and I got discharged on __/__/____ (Date). My patient ID is ___________ (Patient ID). I beg to state that at the time of admission I deposited the amount of _________ (amount) on __/__/____ (Date) and the total bill occurred for an amount of _________ (Amount), which is less.

Therefore, I request you to kindly refund the remaining paid amount of _________ (excessive amount paid). I request you to kindly accept my request and I look forward to hearing back from you.

Thanking You,

Yours Faithfully,
_____________ (Signature),
_____________ (Name),
_____________ (Address)

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