Hospital financial assistance (charity care) request letter template
A ready-to-send letter asking a hospital to apply its financial assistance policy to your bill, citing IRS section 501(r), asking for a hold on collections while it is reviewed, and requesting a refund of anything you already paid above the assistance rate. Fill in the brackets, attach proof of income, send by certified mail and email.
- Send this with the hospital's own financial assistance application (download it from their website; federal law requires them to publish it).
- Attach proof of household income: last year's tax return or three recent pay stubs, plus benefit letters (SNAP, Medicaid, unemployment, SSI). No income? A signed statement explaining that is accepted by most hospitals.
- Send by certified mail to the billing/financial assistance address and by email to patient financial services. Keep copies.
- Ask for three things in writing: a decision, a hold on collections while it's reviewed, and a refund of payments already made above what the policy would have charged you.
- Eligibility and background: hospital charity care guide.
Template
The full text, with every [bracketed] field to fill in, is on the next page. Copy it there and paste it into the company's form or email.
Open the full templateHow to fill it in
- Find the policy first: search "[hospital name] financial assistance policy". Use their form; this letter goes on top of it.
- Percent of FPL: divide your annual household income by the poverty guideline for your household size (1 person $15,960; 4 people $33,000 in 2026) and multiply by 100. Most hospitals give free care under 200% and discounts up to 300–400%.
- Deadline: apply within 240 days of the first post-discharge bill to be inside the federal minimum window. Past it? Send it anyway; many hospitals still approve.
- Already in collections: add the recall request (point 2). Nonprofit hospitals that never screened you before sending the account out are on weak ground.
- Send a copy to the collector too, telling them the bill is under a financial assistance review.
- No answer in 30 days: call patient financial services, then escalate to the hospital's patient advocate, then file complaints with your state attorney general and, for nonprofit hospitals, the IRS (Form 13909).
FAQ
Do I have to apply for Medicaid first?
Many hospitals require it. Apply; a denial letter satisfies the requirement and takes a few weeks.
I already set up a payment plan
You can still apply. If approved, the plan is adjusted or canceled and payments above the assistance rate should be refunded.
Can I use this for a doctor's bill instead of the hospital?
Physician groups have separate policies; send the same letter to their billing office and ask for theirs. Some states require hospital-affiliated physicians to follow the hospital's policy.