If you receive assistance from or live in a home with a family or friends, please have them complete the attached form labeled “Letter of Support.” This will not make them responsible for your medical bills. This will help show how you are able to afford living expenses.

In the body of your letter, explain your financial need in detail and how the assistance you are requesting will help you overcome your financial difficulties. Provide specific examples of how the funds will be used and how they will make a difference in your life.

Patient Eligibility Financial Status - You must have a family income and assets of not more than 600 percent of the federal poverty level ($132,300 for a family of four) at non-rural hospitals, and 300 percent of the federal poverty level ($66,150) for a family of four at rural or critical access hospitals.

A medical hardship letter is used by a person to request partial or full forgiveness of medical debt from a hospital or healthcare provider.

Unfortunately, my circumstances are unlikely to improve in the foreseeable future and I have no assets to sell to help clear my debt. I am therefore asking you to consider writing off my debt as I can see no way of ever repaying it. If you are unable to agree to this, please explain your reasons.

More info

The document provides two sample request letters asking for financial assistance to pay hospital bills. Keep a record of all the calls that you make to the hospital about your bill and write a letter to the hospital that says what you and the hospital.Financial Assistance Applications are available to any patient who expresses a need for financial help. We will accept your application for up to 240 days following the first billing statement for your care. Does anyone in your household want help paying for medical bills from the last 3 months? Advocate's financial assistance program provides discounts to patients (up to 100 percent of hospital charges) who meet financial eligibility guidelines. Such evidence may include hospital bills, paystubs, bank statements, or a letter from the employer. Sample. Janet Franklin 500 W Arlington Ave, Apt 701. You may be able to receive free or discounted care. To request assistance for hospital services, select a Patient Financial Assistance Packet below.

Sample Letter Requesting For Help With Medical Bills In Chicago

Description

Related forms

Show more info

Form Rating

Form popularity

FAQ

How to write a letter asking for financial assistance for medical bills?

How do I write a letter of request for financial assistance?

What is a letter of support for medical bills?

Who qualifies for financial assistance for medical bills in Illinois?

What is a letter of forgiveness for medical bills?

What is an example of a debt forgiveness letter?

More info

Trusted and secure by over 3 million people of the world’s leading companies