Sample letter to licensing and certification by Muskan at Lexcliq

SAMPLE LETTER TO LICENSING AND CERTIFICATION
[DATE]
[YOUR NAME]
[YOUR ADDRESS]
[LICENSING & CERTIFICATION DISTRICT OFFICE ADMINISTRATOR]1
[LICENSING & CERTIFICATION DISTRICT OFFICE]
[DISTRICT OFFICE ADDRESS]
RE: [NAME OF HOSPITAL]’s failure to comply with the financial assistance
guidelines of AB 774
Dear District Administrator [NAME OF ADMINISTRATOR]:
I received care at [NAME OF HOSPITAL] on [DATES OF SERVICE]. The hospital is demanding
payment on this bill, [and/or] my bill has been sent to collections, [and/or] I am being sued for
collection of this bill, [and/or] I was forced to pay more than I owe. My income does not exceed 350%
of the federal poverty level and I am uninsured [or] my annual out-of-pocket medical costs exceed
10% of my income. According to the California Health & Safety Code § 127405, I should be eligible
for charity care or a discount on my charges with an extended payment plan.
[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]
Please review [NAME OF HOSPITAL]’s failure to comply with the requirements of AB 774. I ask
that you do everything in your power to force the hospital to comply as hospitals are required to follow
this statute in order to stay licensed.
I authorize Licensing and Certification to disclose my name to the hospital solely for the purposes of
this investigation. Please require that the hospital reduce or forgive my bill according to their policy
[and/or] reimburse me with interest the amounts I already paid in excess.
Please let me know when you will respond to this complaint and how it is ultimately resolved. Thank
you for your time.
Sincerely,
[YOUR NAME]

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