Cover letter for a financial assistance application.
Send this letter on top of your hospital's financial assistance application. It names every account you want covered, lists the papers you included and asks the hospital to pause collections and answer in writing.
Last updated .
When to use it
- You are sending a hospital's financial assistance (charity care) application.
- You have more than one bill from the same hospital and want them all covered.
- You want a record of what you sent and when.
The letter
Highlighted words in brackets are blanks. Replace each one with your own details.
[Today's date]
[Hospital name] Financial Assistance Office [Financial assistance or billing office address]
Re: Financial assistance application Patient: [Patient's full name] Date of birth: [Patient's date of birth] Account number or numbers: [Account number or numbers] Date or dates of service: [Date or dates of service]
Dear Financial Assistance Office,
I have enclosed my completed application for financial assistance under your financial assistance policy. Please apply it to every account listed above, and to any other bill for care I received at your hospital.
I have included these papers: [The papers you are including]
My household has [Number of people in your household] people. Our total household income before taxes is [Household income per year, before taxes] a year.
While you review my application, please pause collection on these accounts. Please do not send them to a collection agency or report them to a credit bureau.
If anything is missing, please tell me in writing what you need and by what date, and I will send it.
Please send me your decision in writing. If I qualify, please send me a corrected bill and refund any amount I have paid above what I owe.
Thank you,
[Your full name] [Your mailing address] [Your phone number]
How to send it
- Get the application. A nonprofit hospital must post its financial assistance policy and application online for free, with no account needed, and hand out free paper copies Source 1. Ask the billing office or a financial counselor, or look on the hospital's website.
- Ask for your language. If enough people in the hospital's community speak your language, the hospital must translate these papers into it Source 1. Ask for the application in your language.
- Fill in every part of the application. Include the income proof it asks for, such as pay stubs, a benefits letter or a tax return Source 2. Send copies, never originals. List each paper in the letter.
- Send it as soon as you can. A nonprofit hospital must accept applications for at least 240 days (IRS, published July 2, 2026) after the first bill sent after you leave. Many accept later ones too, and some states allow more time Source 2.
- Keep proof. Hand it in and ask for a dated receipt, or use certified mail with a return receipt. Keep a copy of the whole package.
What happens next
Once a nonprofit hospital has your complete application, it must stop extraordinary collection actions and make a decision. If you qualify, it must refund what you already paid above what you owe, unless the difference is less than $5 (IRS, published July 2, 2026), and take reasonable steps to undo collection actions Source 2.
If you qualify, the hospital may not charge you more than the amounts generally billed to insured patients for emergency or medically necessary care Source 3. Your decision letter should say how much, if anything, you still owe.
If the hospital asks for more papers, send them quickly. If it says no, ask why in writing and whether you can ask it to look again. You can still ask for a discount or a plan with our hardship letter. Not sure you qualify? Try our charity care checker, and read our guide to charity care.
Next step
Charity care: how to ask a hospital for financial assistance
If you need help with your own situation, these can help:
LawHelp.org lists free legal aid near you.
Your state attorney general takes complaints about medical bills and debt collectors.
The CFPB complaint portal takes complaints about debt collectors and credit reports.
The hospital's financial assistance office can review your bill and tell you what it offers.
Sources
Note 1 IRS, "Financial Assistance Policy and Emergency Medical Care Policy - Section 501(r)(4)". Published July 3, 2026. Last checked November 2, 2026.
Note 2 IRS, "Billing and Collections - Section 501(r)(6)". Published July 2, 2026. Last checked November 2, 2026.
Note 3 IRS, "Limitation on Charges - Section 501(r)(5)". Published July 3, 2026. Last checked November 2, 2026.
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