Fillable Printable Financial Hardship Letter

Financial Hardship Letter

Financial Hardship Letter for Medical Bills

{Your Name}

{Your Address}

{Your Phone Number}

{Hospital/Clinic/Doctor Name}

{Address}

{Phone Number}

ATTN: {contact person}

{Date}

RE: {consolidation/restructuring/forgiveness} of debt on medical bills for

{Name}, account {number}

To Whom It May Concern:

My name is {Name}, and I was a patient at {hospital/clinic/doctor’s office} on

{date}, where I received {a specific procedure, treatment, etc.}. {Indicate

what your insurance covered of this procedure, or note that you did not

have insurance at the time}.

I have been on a payment plan that has me paying {amount in dollars} per

month. But I have unfortunately run into significant troubles in my life, which have

made it impossible for me to continue to keep up with this payment plan. Due to

{death in the family, loss of a job, other medical problems, etc.}, I am dealing

with making constant decisions about which of my many bills is most important

each month.

I have attached {relevant financial documents} to this letter, so that you can

see that my monthly income is only {amount in dollars}, all of which must go to

{mortgage, rent, other payments}, leaving very little left for the amount I owe

you.

{Indicate how much you can pay each month, or indicate that you would

like to have your debt forgiven due to this hardship}. I hope that we can work

out a plan that will work for both parties.

Please contact me as soon as possible so that we can begin this process.

Sincerely,

{Sender Name}