Hospital financial assistance (charity care) request letter template
Copy the text, replace everything in [brackets], and send it. Go back to the template guide for how to fill it in and where to send it.
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[Your full name]
[Street address]
[City, State ZIP]
[Phone] | [Email]
[Date of birth] | [Patient account number(s): …]
[Date]
VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED, AND EMAIL
[Hospital name]
Patient Financial Services / Financial Assistance Department
[Street address]
[City, State ZIP]
Re: Application for financial assistance – account(s) [number(s)], date(s) of service [dates], total billed $[amount]
To whom it may concern:
I am requesting financial assistance under your Financial Assistance Policy for the account(s) listed above. I have enclosed your completed application and the supporting documents listed at the end of this letter.
MY SITUATION
My household consists of [N] people. My gross household income is approximately $[amount] per year, which is about [X]% of the Federal Poverty Level for my household size. [Add any of the following that apply: I am currently unemployed. / My only income is [Social Security / disability / unemployment]. / I am uninsured. / I have insurance, and the balance after insurance is $[amount], which I cannot pay. / My medical expenses this year exceed [X]% of my household income.]
WHAT I AM REQUESTING
1. That you review my account(s) under your Financial Assistance Policy and apply any free care or discount for which I qualify, including retroactively to the date(s) of service.
2. That you place my account(s) on hold and take no collection action, including referral to a collection agency or credit reporting, while this application is under review. [If the account is already with a collector: I also request that you recall the account from [collector name] during the review, and, if I am found eligible, permanently.]
3. That you send me a written decision, including the discount percentage applied and the remaining balance, if any.
4. [If you have already paid:] That you refund any amount I have already paid above what your policy would have charged an assistance-eligible patient, which I understand cannot exceed the amounts generally billed to insured patients.
5. [If uninsured:] That, if I do not qualify for full assistance, you apply your self-pay or cash discount and quote me the discounted price for these services.
[Include this paragraph for a nonprofit hospital:] As a tax-exempt hospital, you are required under Internal Revenue Code section 501(r) to maintain and publicize a financial assistance policy, to limit charges to assistance-eligible individuals to the amounts generally billed to insured patients, and to make reasonable efforts to determine my eligibility for assistance before initiating extraordinary collection actions. I am asking you to apply those requirements to my account.
If any document is missing or you need clarification, please contact me at [phone] or [email] and I will provide it promptly. I would appreciate a written response within 30 days.
Thank you for your consideration.
Sincerely,
[Signature]
[Printed name]
Enclosures: completed financial assistance application; [most recent tax return / three recent pay stubs / benefits award letter / unemployment determination / signed statement of no income]; copy of the itemized bill; [insurance Explanation of Benefits]; [proof of household size, if requested].