Cover letter for a financial assistance application

Send this with your application. It lists what you enclose and asks the hospital to confirm in writing.

Send this with your application. It lists what you enclose and asks the hospital to confirm in writing.

Date of the letter (required)

Your state (required)

Your full name (required)

Your mailing address (required)

Where the reply should be sent.

Your email or phone (optional)

Hospital or provider name (required)

How will you send it?

Their mailing address (required)

Required when you mail it. The bill or the website lists it.

Account or patient number (optional)

Date or dates of the care (optional)

Is it a nonprofit (tax-exempt) hospital?

Documents you are enclosing

Anything else to add (optional, in English)

It goes into the letter as you type it.

Other formats

Sign the letter, keep a copy and keep proof of how and when you sent it (certified mail with a return receipt is one way).

Federal rules for nonprofit hospitals apply in every state. Free help can review your bill.