My name is {Name}, and on {date} at approximately {time} I was transported via ambulance {miles} from the address at {address} to the {Name} Hospital at {address}.
I suffer from {affliction} and normally have a medical emergency plan in case of an {attack, episode, etc.}. However, during this episode, as I was incapacitated, a concerned stranger called the ambulance.
I would never have requested an ambulance had I been in control of the situation at the time. I do not have health insurance and have a limited income. I understand that the service was provided regardless of my intentions, but I cannot afford this expense.
Attached is my income stub and a worksheet detailing the way it is divided among my monthly necessities such as {rent, mortgage, etc.}. I hope that you understand that this new bill is a charge I cannot hope to meet.
Please contact me as soon as possible so that we can work out an arrangement. I would like to request total forgiveness of the bill. Thank you for your consideration.
Download this hardship letter — free!
Formatted and ready to use with Microsoft Word, Google Docs, or any other word processor that can open the .DOC file format.
Index of Hardship Letter Examples