Sample Letter to Hospital
Dear [HOSPITAL NAME]:
I received medical care at your hospital on [DATE]. I am now receiving bills from the hospital, [and/or] receiving notices from one or more collections agencies, [and/or] being sued for collection of this bill by [INSERT NAME OF AGENCY SUING]. My family income is no more than 350% of the federal poverty level and I am uninsured [or] my out-of-pocket health care costs exceed 10% of my income. According to the Hospital Fair Pricing Act (California Health & Safety Code §127400 et seq), I should be eligible for charity care or a discount payment program offered by the hospital.
[Select all the circumstances which apply]
- I was not given written notice regarding the hospital’s charity care or discount payment policy while in the hospital, or when I was billed, [and/or] in the language I speak.
- The hospital refused to give me an application for charity care or a discount payment program.
- I was not permitted to set up a reasonable payment plan.
- I applied for financial assistance, but the hospital refused to accept my application.
- I applied for financial assistance, but the hospital did not process my application and make a final determination.
- My application for financial assistance was improperly denied. [Explain circumstances]
Until this matter is resolved, any collection activity against me is unlawful. If I am not offered payment assistance as required by law, I will file a complaint with the Department of Health Services or seek other remedy as permitted by the laws of this state. I also ask that you assist me in repairing any damage that may have been done to my credit. Please notify me immediately as to how you intend to resolve this.
cc: [OTHER ENTITIES ATTEMPTING TO COLLECT ON THE BILL]