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Sample Letter Requesting Hospital Financial Assistance

Last reviewed 2026-11-02 · Sample letters

Short answerA financial assistance request letter asks a hospital for a copy of its financial assistance policy and an application, states that you cannot pay the bill in full, and asks the hospital to hold collection while it reviews your request. Include your account details and ask for a written reply within 10 business days.

Who can use this letter?

Anyone with a hospital bill that is hard to pay can ask about financial assistance, sometimes called charity care. It is most relevant at nonprofit hospitals. Under Internal Revenue Code § 501(r), tax-exempt hospital organizations must have a written financial assistance policy, limit charges to patients who are eligible for assistance, and make reasonable efforts before extraordinary collection actions.

Other hospitals may have their own programs, so it is worth asking anyway. Eligibility rules differ, and the hospital's own policy controls.

What should you do before sending it?

Look for the policy on the hospital's website, usually under billing or patient financial services. Read what income levels, household sizes and documents it asks for. If the policy is easy to find, you can reference it by name in the letter.

Then gather the documents. Applications commonly ask for proof of income, household size and sometimes bank statements.

Recent pay stubs or an income letter
Last year's tax return, if you filed one
Proof of any unemployment, disability or benefit income
A list of household members
Copies of the hospital bills and any EOB

How do you customize the letter?

Be honest and brief about your circumstances. You do not need to tell the whole story, but a sentence on what changed, such as a loss of income or a large medical expense, helps. Do not guess at what the policy covers. Ask for the policy and the application, and let the hospital tell you the next step.

If an account is close to collections, say so and ask for a written hold during the review.

Can assistance be combined with other steps?

Yes. You can ask for an itemized bill and check for errors at the same time, because assistance is typically calculated on the correct balance. You can also ask about prompt-pay discounts and payment plans if you do not qualify for full assistance.

What to expect

The hospital may send an application, request documents, or tell you that you are not eligible. If you are denied, ask for the reason in writing and for the policy section it relied on, and ask whether you can reapply if your situation changes. Complaints about a nonprofit hospital's practices can go to your state attorney general, and the IRS publishes an overview of the rules. Medical Bill Dispute Pro helps with billing-error disputes, so it is a different tool from this request, but the two can work together.

Sample letter

[YOUR NAME]
[YOUR ADDRESS]
[CITY, STATE ZIP]
[PHONE / EMAIL]

[DATE]

[HOSPITAL NAME]
Attn: Patient Financial Services
[HOSPITAL BILLING ADDRESS]

Re: Request for financial assistance
Patient: [PATIENT NAME]
Account number: [ACCOUNT NUMBER]
Date of service: [DATE OF SERVICE]
Balance: [AMOUNT]

To Patient Financial Services:

I am writing to request financial assistance for the account above. I am not able to pay this balance in full because [BRIEF REASON, FOR EXAMPLE A CHANGE IN INCOME OR HOUSEHOLD EXPENSES].

Please send me:

1. A copy of the hospital's written financial assistance policy
2. A financial assistance application and a list of documents required
3. Information on how income and household size are evaluated
4. Information on payment plan options for any balance that remains

While you review my request, I ask that you place the account on hold and not refer it to a collection agency or take other collection action. Please confirm the hold in writing.

I am also reviewing the charges on this account and would appreciate an itemized bill. If any part of the balance is corrected, please let me know, since it may affect the amount considered for assistance.

Please respond within 10 business days of receiving this letter. I can be reached at [PHONE / EMAIL].

Thank you for your assistance.

Sincerely,

[YOUR NAME]

Replace every [BRACKETED] placeholder before sending, and keep a copy plus proof of delivery.

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Frequently asked questions

Does financial assistance mean the bill is wiped out?

Not always. Some hospitals discount a portion, some eliminate the balance, and some offer payment arrangements. The amount depends on the hospital's written policy and on your income and household size. The letter only starts the process by asking for the policy and application.

Can I apply after I have already received a collection notice?

Often yes, though policies set their own windows. Ask as early as you can, state that you are applying, and request a hold on collection activity. Nonprofit hospitals must make reasonable efforts to determine eligibility before certain extraordinary collection actions.

What if I am insured?

Some policies include insured patients, particularly for amounts left after insurance, such as deductibles and coinsurance. Ask the hospital whether its policy applies to your balance after your insurer has processed the claim.

How do I find out whether a hospital is nonprofit?

Check the hospital's website, which often says so in its about page, or ask the billing office directly. The IRS publishes information on the financial assistance rules for tax-exempt hospitals, which can help you understand what to expect.

What if the hospital will not send an application?

Ask again in writing and keep the dates. If the hospital is a nonprofit, you can reference its obligation to have a financial assistance policy. You can also contact your state attorney general's consumer protection office and ask for guidance.

Sources and further reading

Not legal or medical advice. Medical Bill Dispute Pro is a software tool that helps you prepare billing dispute letters. It is not a law firm, does not provide legal advice, and cannot guarantee any outcome. Laws and rules change and vary by plan and state; verify important details with the sources linked above, your insurer, or a qualified professional.