This letter asks for the forms. The application is the hospital’s own form. Fill it in and send it back as soon as you can, and keep a copy with the date.
Sample letter to a hospital for financial assistance
It fills in as you type. Anything you leave empty stays in brackets, so you can see what is still missing.
Before you send it
Non-profit hospitals in the US must have a written financial assistance policy, and must mail you a free paper copy of it and of the application form if you ask (IRS, section 501(r)(4)). The federal rules give at least 240 days from the first bill after you leave the hospital to apply, but apply as soon as you can. Each hospital’s policy decides who can get help and how much.
Not sure whether you may qualify? The free charity care check compares your household income with the poverty guidelines and, for 7 states, with the levels their laws set. It runs on your device.
Some hospital policies reach far above the federal poverty line. Free care may be available up to 600% of the poverty guidelines at NYU Langone Health, 400% at Stanford Health Care, and 400% at Cedars-Sinai, each for eligible patients under its own policy.
What charity care is, who decides, and state rules from official sources: Hospital charity care. Have insurance? See whether you can get financial assistance if you have insurance.
Most hospitals also post the policy and the form on their website, often under “financial assistance” or “billing”. The IRS explains the rules for financial assistance policies and for billing and collections.
Dollar For, a non-profit, helps people apply for hospital financial assistance, for free. See dollarfor.org. Already paid and then approved? The guide Refund after hospital financial assistance explains what to ask for. The free refund request letter asks the billing office in writing to confirm any credit balance and refund it.
Where to send it
- Use the address for billing questions or correspondence, not the “remit to” or payment address: it is for payments, and a letter sent there may not reach the people who answer questions. If the bill gives only a payment address, call the number on the bill and ask where written questions go.
- If a collection agency has the bill, write to the address on its notice, before the date the notice gives. (CFPB rule, 12 CFR 1006.34)
- For your insurer, use the address on the denial notice or the Explanation of Benefits (EOB).
How to send it
- A message in the patient portal, or an email: free, and dated. Ask for a written answer.
- A fax: free online fax services exist. Keep the confirmation page.
- Certified Mail with an electronic return receipt, bought at a post office: $9.28 in all. That is $5.55 for Certified Mail, $2.91 for the receipt and $0.82 postage for a 1 oz letter. A paper green card costs $4.65 instead of $2.91. The receipt is proof it arrived. (USPS Notice 123, prices from October 4, 2026; USPS, Certified Mail basics)
- Certified Mail nobody collects is held at the post office for 15 days, then returned to you. USPS keeps its record for 2 years. (USPS, Certified Mail basics; USPS, tracking basics)
- A Certificate of Mailing proves the day you sent it, not that it arrived: $2.45 plus postage, $3.27 in all. (USPS Notice 123, prices from October 4, 2026)
- Keep a copy of your letter and your proof. Send copies of documents, never originals. (CMS: “Don’t mail any original documents”)
Calling the number on the bill to say you are applying also helps. Note the date you sent the letter.
While you wait for the forms
Ask for an itemized bill too, with the free itemized bill letter, and open it in MedBillCheckup. It is read on your device, never uploaded, and the free check shows how many things are worth asking the billing office about. The full list, with the exact questions to ask, is $6.99 for one bill, or included with Pro at $9.99 a month.
Check my bill, freeQuestions
Is this the hospital’s financial assistance application?
No. This letter asks for the hospital’s policy and its application form. Non-profit hospitals must send paper copies by mail, free of charge, if you ask (IRS, section 501(r)(4)). The application is the hospital’s own form, and it often asks about household size and income. Our charity care check and the list of hospital systems show where to start, and find your hospital by state lists local hospitals.
Who can get financial assistance?
Each hospital’s policy sets its own rules, often based on household income and family size, and says whether it also helps people with insurance. The letter does not ask about your income: the hospital’s application form asks for what it needs. Asking costs nothing.
Does this letter pause collections?
Not on its own. Under the federal rules for non-profit hospitals, once the hospital has your complete application, made within the application period, it must hold off on extraordinary collection actions, such as reporting the debt to credit bureaus, until it decides. The application period lasts at least 240 days after the first bill sent after you leave the hospital (IRS, section 501(r)(6); 26 CFR 1.501(r)-1(b)(3) and 1.501(r)-6(c)). That is why returning the hospital’s own form quickly matters. If a collection agency has the bill, also write to the agency itself: our free letter to a collection agency.
What if I already paid some of the bill?
Apply anyway. If a non-profit hospital approves you, the federal rules ask it to refund what you paid for that care above what you owe as an eligible patient, unless the difference is under $5 (IRS, section 501(r)(6)). Only the hospital can confirm the amount.
Can a hospital deny financial assistance?
Yes. Each hospital’s policy sets who qualifies and how much help it gives. At a non-profit hospital, once you send a complete application during the application period, the federal rules ask it to tell you in writing what it decided and why (IRS, section 501(r)(6); 26 CFR 1.501(r)-6(c)(6)). If it thinks you may qualify for Medicaid, it may wait until your Medicaid application has been sent and decided. If the answer is no, compare the reason with the policy, and ask the billing office whether you can send more papers or ask for a review.
Know someone who can’t pay a hospital bill?
MedBillCheckup provides informational assistance only. It does not determine whether a charge is medically necessary, fraudulent, illegal, or definitively incorrect, and it is not a substitute for advice from a lawyer, doctor, insurer, or certified medical billing specialist.