Перевод для понимания. Отправляется письмо на английском.
Заявление на финансовую помощь
Я подаю заявление на финансовую помощь. Моя семья состоит из 3 человек и наш годовой доход $61,000.00, это 223.3% от федеральной черты бедности 2026 года (Federal Poverty Guidelines).
Ваша Политика финансовой помощи указывает скидку 90% при этом уровне дохода.
Заполненная форма финансовой оценки и документы, которые она перечисляет, приложены.
SAMPLE — FICTIONAL DATA. NOT A REAL LETTER.
October 27, 2026
To: Patient Financial Services, Lakeview Demo Hospital
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
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.
Not legal or medical advice. You review and sign every letter.