Charity Care Eligibility Request — Annotated Example
Many nonprofit hospitals maintain a written financial assistance, or "charity care," policy that can reduce or eliminate a bill for qualifying patients — and many people never know to ask. This letter requests a formal evaluation under that policy.
Your real packet includes a letter like this one anda matching phone script — so you're ready whether you write or call.
Sample scenario
- Provider
- St. Brendan's Medical Center (nonprofit hospital)
- Bill
- $9,100 (inpatient stay)
- Situation
- A low-income, uninsured patient received care at a nonprofit hospital and wants to be formally evaluated for charity care based on household income and size.
Recommended approach
- Request a formal evaluation under the hospital's charity care / financial assistance policy (this letter).
- Provide income and household documentation when the hospital asks for it.
- Ask to pause collections while your application is reviewed.
What it can help with
- A reduced balance or full write-off, if you qualify
- A formal review under the hospital's written policy
- A pause on collections during the review
The letter you'd mail or email to the billing office
[Date] St. Brendan's Medical Center Attn: Financial Assistance / Charity Care Office [Provider Address] Re: Request for Charity Care Evaluation Account Number: [Your Account Number] Patient Name: [Your Name] Date(s) of Service: [Service Date] Current Balance: $9,100.00 To Whom It May Concern: I am writing to request that my account be evaluated for assistance under your hospital's financial assistance or charity care policy. I received care at your facility and am currently unable to afford this balance. I understand that many nonprofit hospitals maintain a written charity care policy and screen patients for eligibility based on factors such as household income and family size. My current monthly household income is approximately [amount] and my household size is [number]. I am requesting a copy of your financial assistance application and policy, and I am happy to provide documentation of my income and household to support my request. While my application is being reviewed, I respectfully ask that collection activity on this account be paused. I am committed to resolving this account fairly and to paying any reduced amount I am determined to owe. Please send the application and any next steps to the contact information below. Thank you for your consideration. Sincerely, [Your Name] [Your Contact Information]
Why this letter works
What each part is doing and why it matters.
Asking by name
Requesting evaluation under the "financial assistance or charity care policy" uses the hospital's own program language, which routes your request to the right office.
Hedged but pointed
"Many nonprofit hospitals maintain a written charity care policy" points to a common, real program without overstating any specific legal requirement on this hospital.
Giving the qualifying facts
Volunteering income and household size up front lets them start the eligibility screen immediately instead of going back and forth.
Pause collections during review
A reasonable request that keeps the account from advancing while your application is considered.
What to say if you call instead
Your packet includes a full phone script. Here's a preview of the key pieces.
Call goal
Ask about the hospital's formal charity care or financial assistance program and find out how to apply.
Opening
“Hi, my name is [Your Name]. I'm calling about a balance for services on [Service Date]. I'm having difficulty paying this bill and I'd like to ask about your hospital's charity care or financial assistance program.”
Your ask
“Do you have a formal charity care or financial assistance policy, and can you tell me how to apply?”
If they say…
They say:
"I don't think we have a program like that."
You can say:
"Many nonprofit hospitals are required to have a written financial assistance policy. Can you transfer me to patient financial services so I can ask directly?"
The full script in your packet also includes a call preparation checklist, a documentation form to fill in during the call, and a follow-up email template.
Good for
- Care received at a nonprofit hospital
- Low or limited household income
- Uninsured or underinsured patients
- Large balances relative to income
Not the right fit
- A for-profit provider with no charity program — try Hardship or Settlement
- An insurance denial — use an Insurance Appeal
- Specific wrong charges — use a Billing Error Dispute
This example uses entirely fictional names, providers, and figures. It is not legal, medical, or financial advice — hospital and insurer policies vary. Whether any particular law or program applies depends on your specific situation. Your packet will use the details from your own bill. Review everything before sending, and talk to a professional for complex situations.
Other letter types
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