Free Medical Bill Settlement Request Letter [Sample]

Learn how to write a medical debt settlement request letter. Use our sample medical debt settlement request letter as a template for your request letter.

Medical Debt Settlement Request Letter sample

Your Name
Your Address
City, State, Zip Code


Recipient’s Name
Recipient’s Address
City, State, Zip Code

Dear Name of Recipient,

The purpose of this letter is to formally request a settlement for the medical bills I owe your hospital. 

I regret that I am unable to pay the bill in full at this time because my monthly income has been greatly reduced after the automobile accident in which I broke both of my legs.

I am requesting a payment plan of $100 per month until the time that I am able to continue working and receiving my usual salary. The rehabilitation may take from six to nine months.

At this time, my income is $ and I have a home mortgage of $ to pay. I will pay by check on the 18th of each month beginning DATE.

If this is agreeable to you, kindly send me a letter stating the repayment details as I have described. I can be reached at 555-123-4567 or a, and I would be happy to talk to you and give you more details at any time.


Your Signature
Your Printed Name
List of Enclosures: Resume

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