SAMPLE — FICTIONAL DATA. NOT A REAL LETTER.
Application for financial assistance
Dear Patient Financial Services team,
I am applying for financial assistance. My household has 3 people and our yearly income is $61,000.00, which is 223.3% of the 2026 federal poverty guidelines.
Your Financial Assistance Policy lists a 90% discount at this income level. Policy p.11
The completed Financial Evaluation Form and the documents it lists are attached.
Attached: Financial Evaluation Form; Documents listed in Table C of the form.
Sincerely,
Maria Sample
12 Example Lane
Riverton, ST 12345
(555) 010-0199
Maria Sample
12 Example Lane
Riverton, ST 12345
(555) 010-0199
Signature
Where this comes from (for you, not part of the letter)
- Financial Assistance Policy (current public version), page 11:
201% - 250% of FPG 90% Discount
Rules: the public Financial Assistance Policy and form of Memorial Regional Hospital (FL; MHS = Memorial Healthcare System), applied to the fictional Lakeview Demo Hospital case.