Generate your Charity Care request letter
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Printed document language: English
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July 19, 2026 To the Billing Department at [Hospital name], Re: Account / Bill Number [Account / bill number] I am writing to formally apply for Financial Assistance (Charity Care) regarding my recent medical bill. Based on federal IRS Β§501(r) requirements for non-profit hospitals (26 U.S.C. Β§501(r)) and your hospital's published Financial Assistance Policy (FAP), I believe I qualify for assistance, as my household income falls within the eligibility range published in your Financial Assistance Policy. Please find attached the supporting documentation: - [ ] Completed Hospital Financial Assistance Application - [ ] Proof of household income (most recent tax return, last 3 paystubs, or Social Security award letter) - [ ] Government-issued photo ID - [ ] Proof of residency I respectfully request that you: 1. Place my account on hold and pause any collections activity while this application is reviewed. 2. Provide a written determination of my eligibility within a reasonable timeframe. 3. Send an itemized bill so I can review the charges line by line. Thank you for your time and assistance. Please contact me in writing at the address on file if any additional information is needed. Sincerely, [Your full name]
Template only. Review with the hospital's Financial Assistance Policy (FAP) and adjust to your situation. Send by certified mail or hospital portal so you have proof of delivery.