Request hospital financial assistance

Date:
Hospital financial counseling or billing:
Statement date and approximate balance (no member ID):
Service date (general):

Please send the current financial-assistance policy and application. I am asking whether this balance qualifies for a discount or an interest-free written payment plan. Please confirm how to apply and how long collections will be paused while the application is reviewed.

I will submit the application on the hospital portal or by mail. I am not sending medical records through third-party sites.