Sample Letter to Hospital - Financial Assistance & Charity Care (AB 774) - Suspension Request

Sep 16, 2026

Sample hospital and collection-agency correspondence templates for requesting suspension of bill collection while determining eligibility for charity care or discounted payment under AB 774 (California Health & Safety Code § 127400 et seq). Includes eligibility criteria based on uninsured status or high medical costs (at/below 350% of the federal poverty level), checklist-style circumstance selections, deadlines, and notices of unlawful collection activity. Also provides a licensing and certification complaint letter directed to a district administrator when hospitals fail to comply.

LanguageEnglish

CategoryLetters

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

SAMPLE LETTER TO HOSPITAL

Eligibility basis under AB 774

Circumstance selections

SAMPLE LETTER TO COLLECTION AGENCY

Request to suspend collection

California Hospital Fair Pricing policies references

Circumstance selections

SAMPLE LETTER TO LICENSING AND CERTIFICATION

SAMPLE LETTER TO HOSPITAL [DATE] [YOUR NAME] [YOUR ADDRESS] [HOSPITAL NAME][HOSPITAL ADDRESS] Dear [HOSPITAL NAME]: I received medical care at your hospital on [DATE] . I am now receiving bills from the hospital,[and/or] receiving notices from one or more collections agencies,[and/or] being sued for collection of this bill by [INSERT NAME OF AGENCY SUING] . My family income is no more than 350% of the federal poverty level and I am uninsured [or] my out-of-pocket healthcare costs exceed 10% of my income. According to AB 774 (California Health & Safety Code § 127400 et seq), I should be eligible for charity care or a discount payment program offered by the hospital. [Select all the circumstances which apply] • I was not given written notice regarding the hospital’s charity care or discount payment policy while in the hospital, or when I was billed,[and/or] in the language I speak. • The hospital refused to give me an application for charity care or a discount payment program. • I was not permitted to set up a reasonable payment plan. • I applied for financial assistance, but the hospital refused to accept my application. • I applied for financial assistance, but the hospital did not process my application and make a final determination. • My application for financial assistance was improperly denied. [Explain circumstances] Until this matter is resolved, any collection activity against me is unlawful. If I am not offered payment assistance as required by law, I will file a complaint with the Department of Health Services or seek other remedy as permitted by the laws of this state. I also ask that you assist mein repairing any damage that may have been done to my credit. Please notify me immediately as to how you intend to resolve this. Sincerely, [YOUR NAME] cc: [OTHER ENTITIES ATTEMPTING TO COLLECT ON THE BILL] SAMPLE LETTER TO COLLECTION AGENCY [DATE] [YOUR NAME] [YOUR ADDRESS] [COLLECTION AGENCY NAME][COLLECTION AGENCY ADDRESS] Re: Request for Suspension of Collection Pending Determination of Eligibility for Hospital Financial Assistance Dear [COLLECTION AGENCY NAME] My hospital bill from [HOSPITAL NAME] has been sent to you for collection. I believe that I should have been offered and granted financial assistance for the medical services that I received at [HOSPITAL NAME] on [INSERT DATE(S) OF SERVICES] . California has a new Hospital Fair Pricing Policies law that requires hospitals to have written financial policies and notify their patients of these policies. CA Health & Safety Code § 127400 et seq. According to the law “Uninsured patients or patients with high medical costs who are at or below 350 percent of the federal poverty level . . . shall be eligible to apply for participation under each hospital’s charity care policy or discount payment policy.” CA Health & Safety Code § 127405(a) . [Select the circumstances that apply] • I am uninsured and the hospital did not inform me that I could apply for financial assistance or seek coverage from government program as required by CA Health & Safety Code § 127410(a) and § 127420(b) . I am now trying to do so. • I have applied for financial assistance and am waiting for a decision from the hospital. CA Health & Safety Code § 127425(e) requires that you wait to collect on this bill. • The hospital wrongfully denied me financial assistance according to the requirements of CA Health & Safety Code § 127400 et seq and I am appealing this decision [or] filing a complaint with the Department of Health Services. • According to CA Health & Safety Code § 127425(d), you may not report me to a credit reporting agency or commence a civil action against me for 150 days after I was initially billed. If you continue to try to collect on this bill before a determination of financial assistance is made on my account, you may be in violation of the Rosenthal Fair Debt Collection Practices Act and the federal Fair Debt Collection Pra

FAQs

What legal basis does the template cite for charity care or discounted payments?

It cites AB 774 (California Health & Safety Code § 127400 et seq) and related sections governing eligibility for participation in each hospital’s charity care or discount payment policy.

What does the hospital letter ask the recipient to do?

It asks the hospital to resolve eligibility for financial assistance, stop or refrain from unlawful collection activity, and notify the sender of the intended resolution, including assistance to repair credit damage.

How should the collection-agency letter be used?

Send it to request suspension/cessation of collection until the hospital determines eligibility for financial assistance, referencing requirements on notice, waiting periods, and limits on reporting or initiating civil action.

When is the licensing and certification letter appropriate?

Use it when the hospital is believed to fail to comply with AB 774 financial assistance guidelines, including demanding payment improperly, sending bills to collections, or forcing payments beyond what is owed.

Sep 16, 2026

Upload by Aria Callaghan