[Your letterhead, if desired; if not, your return address]
[Date of letter-month, day, and year]
[Recipient's first and last names]
[Street or P.O. box address]
[City, State ZIP code]
Dear [recipient's name]:
I have received the bill for $743.50 from your office, which is for the dental treatments I received last month. Given the large amount of this bill, I would like to request a payment arrangement with your office so that I can pay the balance in installments.
Please call me at 555-2222 to let me know whether I can arrange a payment plan like this, or what payment options you offer. I look forward to hearing from you, and thank you for your time.
[Sender's first and last names]