[YOUR FULL NAME]
[YOUR STREET ADDRESS]
[CITY, STATE, ZIP CODE]
[YOUR PHONE NUMBER]
[YOUR EMAIL ADDRESS]
[DATE]
Patient Financial Services
[HOSPITAL NAME]
[HOSPITAL MAILING ADDRESS]
[CITY, STATE, ZIP CODE]
Re: Request for Financial Assistance Application — Account / Patient Number: [ACCOUNT OR PATIENT NUMBER]
Dear Patient Financial Services Representative:
I am writing to formally request a Financial Assistance Program (FAP) application for the medical services I received at [HOSPITAL NAME] on or around [DATE(S) OF SERVICE]. I understand that, as a nonprofit hospital operating under § 501(c)(3) of the Internal Revenue Code, [HOSPITAL NAME] is required by IRC § 501(r) and 26 CFR § 1.501(r)-4 to maintain a written Financial Assistance Policy and to make FAP applications available to patients who may qualify.
Account Information
| Patient Name: | [YOUR FULL NAME] |
| Date(s) of Service: | [DATE(S) OF SERVICE] |
| Account / Bill Number: | [ACCOUNT OR BILL NUMBER] |
| Total Amount Billed: | $[AMOUNT BILLED] |
Basis for This Request
I believe I may qualify for financial assistance based on my household income and current financial circumstances. I respectfully request that you:
- Provide me with a copy of the hospital's current Financial Assistance Policy (FAP) and the plain-language summary;
- Provide me with a completed FAP application form; and
- Place a hold on any collection activity, including referral to a collection agency or reporting to credit bureaus, while my application is under review, as required by 26 CFR § 1.501(r)-6.
Income and Household Information (to assist with initial screening)
| Household Size: | [NUMBER OF PEOPLE IN HOUSEHOLD] |
| Approximate Annual Household Income: | $[APPROXIMATE ANNUAL INCOME] |
| Insurance Status: | [UNINSURED / INSURED — name of insurer and remaining balance after insurance] |
I am prepared to provide documentation of my income and financial situation, including [check all that apply]:
- ☐ Most recent federal tax return (Form 1040)
- ☐ Recent pay stubs (last 2–3 months)
- ☐ Proof of government assistance (Medicaid, SNAP, SSI, etc.)
- ☐ Unemployment benefit statement
- ☐ Bank statements
- ☐ Other: [DESCRIBE]
Please contact me at the phone number or email address above to advise me of next steps or to request any additional documentation. I am committed to resolving this balance and appreciate your assistance.
Sincerely,
[YOUR PRINTED NAME]
Enclosures: [List any income documentation included with this letter]