Nonprofit hospitals are required under federal tax law (IRC 501(r)) to maintain a Financial Assistance Policy (FAP), commonly called charity care. This free template is a cover letter for your FAP application that asks the hospital's financial assistance office to screen you and pause collection activity while it reviews your request.
A full letter you can copy: patient and account identifiers, household size and income section, a hardship-circumstances section, and a request that the account not be sent to collections while your application is under review.
You can typically apply within 240 days of your first post-discharge bill, and you can often still apply even after an account has gone to collections — confirm the hospital's exact process with its financial assistance office.
Medigami's $149 Bill Rescue service reviews your bill and drafts documents like this for you — done in 48 hours. You review, sign, and submit it yourself.
Educational free template only. Not legal or financial advice. Eligible patients generally cannot be charged more than amounts generally billed to insured patients for emergency or medically necessary care — confirm the specific hospital's policy for exact terms.
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