Medical Prescription

{Your Name}
{Your Address}
{Your Phone #}

{Date}

Dear {Pharmaceutical Representative}:

I am writing to request a reduced price for {dosage} of {prescription drug} over the next {amount of time} due to financial hardship.

Enclosed is a statement from my doctor verifying that the prescription is for {condition} and that it is the only medication available to treat {condition}. If I do not take this medication, {negative result}.

Due to {reason}, I am currently uninsured, and I do not qualify for financial assistance from the state. I desperately need this prescription filled, but I am unable to afford the high cost at the time. Enclosed are my bank statements and income stubs that prove I cannot spare the money without {losing my home, declaring bankruptcy, etc.}.

I am deeply appreciative of any help you can give me in gaining relief from {symptoms} as quickly as possible. Thank you for your consideration.

Sincerely,

{Sender Name}

Index of Hardship Letter Examples