Application for financial assistance

Dear Patient Financial Services team,

I am applying for financial assistance. My household has 3 people and our yearly income is $58,000.00, which is 212.3% of the 2026 federal poverty guidelines.

Your Financial Assistance Policy, Revised May 2026 lists a 90% discount at this income level. Policy p.11

The completed Financial Evaluation Form and the documents it lists are attached.

Attached: Financial Evaluation Form (filled, sign before sending); Documents listed in Table C of the form.

Sincerely,
Daniela Castillo
9349 Seagrape Ln Apt 717
Bayside, FL 33067
(954) 555-0161

Signature

Where this comes from (for you, not part of the letter)

Financial Assistance Policy, Revised May 2026, page 11: Memorial Regional Hospital BALANCES DUE FROM PATIENT INCOME AMOUNT OF DISCOUNT Up to 200% of FPG 100% Discount 201% - 250% of FPG 90% Discount 251% - 300% of FPG 85% Discount 301% - 350% of FPG 83% Discount 351% - 400% of FPG 83% Discount