Financial Assistance (Charity Care) Application

SAMPLE — not a real letter. Names, amounts, and account numbers are fictional.

April 27, 2026 Jordan Sample 123 Sample Street Anytown, ST 00000 Northbridge Health System Financial Assistance Office 400 Example Avenue Anytown, ST 00000 RE: Request for financial assistance — Account ACCT-0000-SAMPLE, balance $7,480.00, dates of service January 18–20, 2026 Dear Financial Assistance Office: I am writing to apply for financial assistance for the account above, which arose from a three-day inpatient stay in January 2026. I am insured through a high-deductible plan, and the balance reflects the deductible and coinsurance that remain after my insurer paid its share. My household consists of three people, and our total annual income is approximately $41,000. The balance on this account is more than two months of our income, and I cannot pay it in full without falling behind on rent and other necessities. I am asking to be evaluated under your financial assistance policy for a full or partial reduction of this balance. If Northbridge Health System is a nonprofit hospital, I understand that Section 501(r) of the Internal Revenue Code requires it to maintain a written financial assistance policy, to make that policy and a plain-language summary available to patients, and to refrain from extraordinary collection actions before making reasonable efforts to determine whether a patient qualifies. Please send me a copy of the policy, the plain-language summary, the application form, and the income limits used to determine eligibility. If the hospital is not subject to Section 501(r), please send the details of whatever financial assistance or discount program you offer. I will promptly provide any documentation you need, including recent pay stubs, my most recent tax return, and a statement of household size and expenses. I would also like to know whether assistance, if granted, can be applied to this balance and to any other open accounts from the same admission, including separately billed physician charges. While my application is under review, I respectfully ask that you place this account on hold, without late fees or interest, and not refer it to a collection agency. Thank you for your consideration. I look forward to your reply. Sincerely, Jordan Sample Enclosures: Statement dated April 10, 2026; summary of household income and size