Financial assistance request letter for a hospital bill

Updated October 1, 2026 · How we write our guides

When to use it

Use this letter to apply for a hospital's financial assistance, often called charity care. Send it with the hospital's application and proof of income. It asks the hospital to hold your bill, tell you what's missing, and decide in writing. Nonprofit hospitals must accept applications for at least 240 days after your first bill.

A hospital bill can be more than you can pay, even after insurance. Many hospitals lower or cover bills for people who qualify, but you usually have to ask. This letter helps you apply in writing. Our guide to hospital charity care explains who qualifies and how the rules work.

When to use this letter

Use it to apply for financial assistance from a hospital, or to ask for the application. It works whether or not you have insurance. Many policies help with what you owe after insurance, like your deductible and coinsurance.

Nonprofit hospitals must have a written financial assistance policy for emergency and other medically necessary care. Other providers may have one too, so it's worth asking. State rules may add more protections.

Get the policy and application first

Look for the hospital's financial assistance policy, application, and plain-language summary. Check the hospital's website, or call the number on your bill. Nonprofit hospitals must mail you free paper copies if you ask.

Read the income limits, the deadline, and the list of documents it wants. Our charity care screener shows where your income falls against the 2026 federal poverty guidelines. If you're close to a limit, apply anyway.

What to fill in

Account number: on your bill. If you have bills from more than 1 visit, list each account number.
Date of your first bill: the date on the first bill you got after your care. It starts the application window.
Household size and income: use the hospital's own definitions if its policy gives them.
Recent changes: a job loss or a drop in hours may matter more than last year's tax return. If nothing changed, write "None."

Leave out your Social Security number and any bank or card numbers. If the hospital's form asks for something sensitive, put it on the form, not in this letter.

Fill in your details

Optional. What you type stays on this page. We don't save it or send it anywhere.

Your name

Your address

City, state ZIP

Your phone

Your email

Today's date

Hospital name

Hospital billing address

Patient name

Account number

Date of service

Date of first bill

Balance

Household size

Yearly household income

Recent changes, or none

Your letter

[YOUR NAME] [YOUR ADDRESS] [CITY, STATE ZIP] [YOUR PHONE] [YOUR EMAIL] [TODAY'S DATE] [HOSPITAL NAME] Attn: Financial assistance [HOSPITAL BILLING ADDRESS] Re: Application for financial assistance Patient: [PATIENT NAME] Account number: [ACCOUNT NUMBER] Date of service: [DATE OF SERVICE] Date of first bill: [DATE OF FIRST BILL] Current balance: $[BALANCE] To the financial assistance office: I am applying for financial assistance under your financial assistance policy for the account above. My completed application and copies of the documents it asks for are enclosed. My household has [HOUSEHOLD SIZE] people. Our yearly household income is about $[YEARLY HOUSEHOLD INCOME]. Recent changes to our income: [RECENT CHANGES, OR NONE] While you review my application, please hold my account and pause any collection actions. If this account is with a collection agency, please tell the agency that I have applied. If anything is missing, please tell me in writing what you need and how long I have to send it. Please also tell me which doctors and other providers who treated me are covered by your policy. If I qualify, please apply the help to every bill for this care. Please refund any amount I have paid above what I owe under the policy. Please send your decision to me in writing, with the reason for it. You can reach me at [YOUR PHONE] or [YOUR EMAIL]. Thank you, [YOUR NAME]

Highlighted words are blanks you haven't filled in yet.

What to attach

Send copies, not originals. Most applications ask for:

The hospital's completed application form
Proof of income, like recent pay stubs or last year's tax return
A list of household members, if the form doesn't already ask
Proof of a recent change, like a layoff letter, if you have 1
Your explanation of benefits (EOB) and the bill, if you have insurance

How to send it

Send it the way the hospital's policy says. Many take applications by mail or online. If you mail it, use certified mail with a return receipt. If you apply online, save the confirmation page.

Keep a copy of everything you send, and note the date. Then call the billing office. Say you've applied, and ask them to hold your account. If a collector has the bill, tell the collector too, and ask it to pause.

What happens next

Ask how long the review takes, and follow up if you don't hear back. At a nonprofit hospital, the decision must come in writing and explain the reason.

When you get the decision, check that the help was applied to every bill from that care. If you don't qualify, ask whether you can reapply if your income changes. You can still ask for an interest-free plan with our payment plan request letter. If the bill is with a collector, see your rights when a medical bill is in collections.

Common questions

How long do I have to apply for financial assistance?

At a nonprofit hospital, you can apply for at least 240 days after the first bill it sends after your care. Some hospitals accept applications even later, so ask. Other hospitals set their own deadlines, and some states add more rules. Read the hospital's policy for its exact deadline.

Do I need to use the hospital's own form?

Usually, yes. Most hospitals have an application form, and this letter works as a cover letter for it. Nonprofit hospitals must post the policy and application on their website and mail you free paper copies if you ask. If you can't get the form yet, send this letter to ask for it.

What happens to my bill while the hospital decides?

Ask the hospital to hold it. If you send a complete application to a nonprofit hospital, it must pause serious collection steps while it decides. Those include credit reporting, selling the debt, and lawsuits. If your application is missing something, it must tell you how to complete it and give you a reasonable chance to do so.

What if I already paid part of the bill?

You can still apply if you're within the application period. At a nonprofit hospital, if you qualify, it must refund what you paid beyond what you owe under its policy. It must also take reasonable steps to reverse collection actions, like a credit report entry. Keep receipts for every payment you made.

Sources

Financial assistance policies (FAPs), Internal Revenue Service. Accessed October 1, 2026.
Billing and collections: section 501(r)(6), Internal Revenue Service. Accessed October 1, 2026.
Apply for medical bill financial assistance, Centers for Medicare & Medicaid Services. Accessed October 1, 2026.

This is general information, not legal or medical advice. Rules can depend on your plan and your state. Romi Care isn't an insurer, law firm, collection agency, or government program.