Patient letters

Pick the letter that fits, fill in the blanks, then copy or download it. Everything stays on your device — nothing you type is sent or saved. These are templates, not legal advice.

Not sure which letter you need? See the Patient Letter Hub. Appealing an insurance denial? Use the appeal letter builder. Asking for charity care? Use the financial assistance letter.

Hardship settlement request

Law:: Nonprofit hospitals must have a financial assistance policy (26 U.S.C. §501(r)); credit reporting accuracy is governed by the Fair Credit Reporting Act.
Timing:: Get any agreement in writing before you pay. Removal from a credit report is not guaranteed.
Send to:: The provider’s billing office, or the collector if the account was sold.

Your letter

[Your name]
[Your address]

[Date]

[Recipient name and address]

Re: Hardship settlement request
Account/Reference: [Account number]

I am unable to pay the full balance on this account because of financial hardship.

I first ask that you screen this account for financial assistance or charity care. If assistance is not available, I offer [amount] as payment in full.

If you accept, please confirm in writing before I pay that (1) this amount settles the account in full, (2) no remaining balance will be sold or collected, and (3) the account will be reported as paid in full or removed from any credit report.
Sincerely,

[Your name]

Keep a copy and send by certified mail with return receipt when you can. Replace anything in [brackets] before sending.