Charity Care Letter Sample

Hospitals, clinics, and other healthcare providers often offer charity care to patients who cannot afford to pay for medical services. A wellwritten charity care lettersometimes called an financial assistance requestexplains the patients situation, outlines the providers policies, and requests formal documentation of the assistance being offered.

Why a Charity Care Letter Matters

Clarity: It clarifies the amount of debt being forgiven, reduced, or deferred.
Compliance: Many states require written documentation for charitable assistance to meet Medicaid, Medicare, or IRS regulations.
Recordkeeping: Both the provider and the patient need a paper trail for future reference or audits.
Patient trust: A courteous, transparent letter reassures patients that they are being treated fairly.

Key Elements of a Charity Care Letter

Below are the sections you should include. The order can be adapted to suit the organizations style, but each component should be present.

Header Provider name, address, phone, and date.
Patient Information Full name, medical record number, and contact details.
Reference to Policy Cite the specific charity care or financial assistance policy (e.g., Per our 2024 Financial Assistance Policy, Section4).
Statement of Eligibility Briefly summarize why the patient qualifies (income level, insurance status, etc.).
Details of Assistance Amount forgiven, percentage of the bill covered, any payment plan, and the timeframe.
Conditions & Responsibilities Any documentation the patient must provide, future obligations, or required followup.
Contact Information Who to contact for questions.
Signature Block Name, title, and signature of the authorized representative.

Sample Charity Care Letter

Charity Care Letter Sample[Providers Letterhead] Date: _______________________Patient Name: _______________________________ Medical Record #: ___________________________ Address: ___________________________________ City, State ZIP: _____________________________ Re: Charity Care / Financial Assistance Account # ___________Dear ________________________,We have reviewed your request for financial assistance regarding the medical services rendered on __________. In accordance with the [Hospital Name] Charity Care Policy (Policy #202401, effective January12024), you meet the eligibility criteria for assistance because:* Your household income is at or below 200% of the Federal Poverty Level (FPL). * You are uninsured and have no other source of coverage. * You have provided the required documentation (tax return, pay stubs, and a completed financial hardship questionnaire).Based on this review, we are pleased to inform you that the following assistance will be applied to your account:* **Total charges:** $__________ * **Charity care amount granted:** $__________ (____% of the total balance) * **Remaining balance:** $__________ (to be paid under a 12month interestfree installment plan)**Payment Plan Details** Monthly payment: $__________ First payment due: __________ Final payment due: __________Please note the following conditions:1. You must continue to submit updated financial information annually. 2. If your financial circumstances improve significantly, the charity care amount may be reassessed. 3. All payments must be made by the dates listed above; failure to do so may result in the reinstatement of the original balance.If you have any questions or need further assistance, please contact our Financial Assistance Office at (555)1234567 or email finance@hospital.org MonFri, 8am5pm.Sincerely,_____________________________ [Name], [Title] [Hospital Name] [Phone] | [Email]Enclosures: 1. Copy of Charity Care Policy 2. Completed Financial Hardship Questionnaire (for your records) 3. Payment Plan Agreement

Customizing the Template

While the sample above is a solid starting point, you may need to adjust the letter for your organizations specific requirements:

State regulations: Some states require a minimum amount (e.g., 50% of the bill) to qualify as charity care.
Nonprofit status: If your facility is a 501(c)(3), you may need to include a statement about taxexempt status.
Electronic delivery: For patient portals, replace the physical signature block with a typed name and electronically signed.

Best Practices for Writing the Letter

Use plain language. Avoid medical jargon and legalese that could confuse the patient.
Be empathetic. Acknowledge the difficulty of the situation and express genuine willingness to help.
Stay consistent. Use the same terminology for charity care, financial assistance, or hardship relief throughout the document.
Proofread. Errors can undermine credibility; doublecheck figures, dates, and contact information.
Document everything. Keep a copy of the signed letter and any supporting paperwork in the patients chart.

Resources & Further Reading

Creating a clear, compassionate charity care letter not only helps patients understand their options but also protects healthcare providers from compliance issues. Use the sample and guidelines above as a foundation, then tailor the language to reflect your organizations policies and the specific needs of each patient.

Reference Files For Charity Care Letter Sample

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