Перевод для понимания. Отправляется письмо на английском.
Заявление на финансовую помощь
Я подаю на финансовую помощь. В моей семье 3 человека и наш годовой доход $58,000.00, это 212.3% 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 указанные в ней документы приложены.
SAMPLE — FICTIONAL DATA. NOT A REAL LETTER.
March 2, 2026
To: Patient Financial Services, Seaside Regional 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 $58,000.00, which is 212.3% 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,
Daniela Castillo
9349 Seagrape Ln Apt 717
Bayside, FL 33067
(954) 555-0161
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 Seaside Regional Hospital case.
Not legal or medical advice. You review and sign every letter.