Sample Request Letter for Financial Help for Medical Treatment

Learn how to write a request letter for financial help for medical treatment. Use our sample request letter for financial help for medical treatment as a template for your letter asking for help.

sample request letter for financial help for medical treatment

Name
Address
City, State, Zip Code

DATE

Name of Receiver
Name of Organization
Address of Organization
City, State, Zip Code

RE: Requesting financial help for medical treatment

Dear Name of Receiver,

This letter is to request assistance for purchasing the medications I need to treat [NAME of DISEASE]. The medicine was prescribed by my specialist [NAME of DOCTOR] on [DATE].

I was referred to your organization by my doctor because the medications I need to take for the rest of my life are too expensive for me to afford on my fixed retirement income. I understand that you give assistance to people who are eligible either by helping them pay for their medications or with free or very low-cost medicines. 

I have completed the application form on your website and enclose a copy of it here. I have also enclosed a letter from my doctor stating that the medicine is required for me to continue my everyday activities.

Also, I have enclosed a copy of my medical record regarding my disease including a copy of the prescription and my last three bank financial statements. As you can see, the cost of the medicine, which is COST, is a very high percentage of my monthly income. 

Thank you for your attention to this matter. I can be reached at 555-123-4567 or at Name@email.com if you have any questions or require more information. I hope to have a favorable reply from you soon. 

Sincerely, 

Signature
Name of Sender
List of enclosures