Subject: Request for Medical Financial Assistance Due to Hardship

[Date: 3/12/2024]

[Medical Institution Name]
[Medical Institution Address]
[City, State, ZIP Code]

Dear [Medical Institution's Financial Aid Office/Financial Counselor's Name],

I am writing to formally request financial assistance for medical bills incurred at your facility due to a recent [medical condition/treatment]. My name is [Your Full Name], and I received care at [Medical Institution Name] from [date of treatment].

Unfortunately, despite having [type of insurance, if any], the expenses associated with my care have placed an enormous financial burden on my shoulders, as I am currently struggling to meet even my basic household needs. The cost of [specific treatment or procedure] has been a significant hardship due to my current financial situation, which includes [briefly list major financial challenges, e.g., job loss, reduced income, caring for a loved one, etc.].

I am reaching out to request assistance as I currently [explain your income situation briefly, such as unemployment, disability, low-income status, etc.]. Attached, please find documentation of my financial status, which includes [mention types of documents, e.g., bank statements, pay stubs, tax returns].

I request that you consider either reducing or eliminating my medical debt or offering an extended payment plan suited to my financial state, which would allow me to manage the outstanding bills without forgoing essentials like [food, housing, utilities, etc.].

Please advise me on the proper steps to take to apply for any financial aid programs you have for patients facing hardship, or if there are any charity care programs available. 

I am hopeful that [Medical Institution Name] understands the gravity of my financial constraints and can offer assistance to prevent the situation from worsening.

Thank you very much for taking the time to consider my request. I am willing to provide any additional information required and am looking forward to your compassionate response.

Sincerely,

[Your Full Name]
[Your Address]
[City, State, ZIP Code]
[Your Phone Number]
[Your Email Address]

[Attachments: Financial Documents]