Letter

Hospital charity care request

You got a hospital bill you cannot pay, often after a DKA admission. Nonprofit hospitals are legally required to have a financial assistance policy and most patients never apply.

Before you send this

The itemized bill and the account number
Proof of household income and household size
The hospital financial assistance policy, which must be published on their website
The date of service, since some hospitals allow retroactive applications for months or longer

[DATE]

[HOSPITAL NAME]

Attn: Financial Assistance / Patient Financial Services

[ADDRESS]

Re: Application for financial assistance

Patient: [PATIENT NAME], DOB [DOB]

Account number: [ACCOUNT NUMBER]

Date(s) of service: [DATES]

Balance: $[AMOUNT]

To whom it may concern,

I am requesting financial assistance under your Financial Assistance Policy for the balance above.

Household information:

- Household size: [NUMBER]

- Annual household income: $[AMOUNT]

- This is approximately [PERCENT]% of the federal poverty level for my household size.

- Insurance status at the time of service: [uninsured / insured with an unmet deductible of $AMOUNT / other]

Documentation enclosed: [tax return / pay stubs / benefit award letter / bank statements].

Circumstances:

I have insulin-dependent diabetes. This admission was for [REASON, for example diabetic ketoacidosis] on [DATE]. [One or two sentences on why paying this balance is not possible: fixed income, ongoing insulin and supply costs, other medical debt.]

I am requesting:

1. Full or partial charity care write-off under your policy.

2. In the alternative, an interest-free payment plan at an amount I can sustain, which is $[AMOUNT] per month.

3. A hold on collections activity while this application is under review.

4. A written decision explaining how my eligibility was determined.

Please also send me an itemized bill for these dates of service if one has not already been provided.

Sincerely,

[YOUR NAME]

[PHONE]

[EMAIL]

[MAILING ADDRESS]

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