Nonprofit hospital financial assistance (incl. retroactive refunds)

26 CFR 1.501(r)-4 (FAP), -5 (charges limited to AGB), -6 (240-day application period, ECAs suspended, refund of payments above the FAP amount)

2026-11-10

To: [provider name]
Re: account [account number]
From: [Your name]

Please treat this as my application for financial assistance under your Financial Assistance Policy (26 CFR 1.501(r)-4 to -6). Please send the application form and list of documents, suspend any extraordinary collection actions while it is pending, and refund any amount I paid above what I owe once I am found eligible.

Please reply in writing.

[Your name]

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Fill in the [brackets], sign, keep a copy, and send it yourself (certified mail for debt and credit letters).

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you. BillAdvocate is not a law firm and is not your lawyer: letters are drafted by software (and, only if you ask, reworded by an AI service) from what you enter, and no lawyer has reviewed them. Check every fact, amount and date before you send, and talk to a lawyer or legal aid office if you are being sued or a deadline is close. These letters are not a substitute for the advice of an attorney.