Life often throws unexpected challenges our way. Medical issues can appear without warning, leaving us looking for help. Many people find themselves needing assistance but struggle with how to ask properly.
Writing a letter to request medical help doesn’t have to be hard. With the right approach, you can clearly explain your situation and get the support you need. These sample letters will guide you through the process step by step.
Sample Letters of Request for Medical Assistance
Here are fifteen different letter templates you can use when requesting medical assistance.
1. Basic Request for Financial Medical Assistance
Subject: Request for Financial Assistance for Medical Treatment
July 10, 2025
Mr. Thomas Clark
Director of Patient Financial Services
City General Hospital
555 Healthcare Avenue
New York, NY 10001
Dear Mr. Clark,
This letter serves as my formal request for financial assistance regarding my upcoming heart surgery scheduled for August 15, 2025, at City General Hospital.
My doctor, Dr. Sarah Johnson, has diagnosed me with a serious heart condition that requires immediate surgical intervention. The estimated cost of this procedure is $85,000, which exceeds my financial capability. Despite having health insurance, my policy will only cover 60% of the total cost, leaving me with a significant amount to pay out-of-pocket.
My current financial situation makes it impossible for me to afford this essential treatment. I recently lost my job due to downsizing, and my savings have been depleted due to previous medical treatments. My monthly income from unemployment benefits is barely enough to cover basic living expenses.
I kindly request your hospital’s financial assistance program to help cover part or all of my remaining medical costs. I have attached all relevant documentation, including my income statements, medical reports, insurance details, and a letter from Dr. Johnson confirming the necessity of this procedure.
Thank you for considering my request. Your assistance would literally save my life and give me a chance to recover both physically and financially.
Sincerely,
Robert Williams
123 Main Street
Apartment 4B
New York, NY 10002
Phone: (555) 123-4567
Email: robert.williams@email.com
2. Letter to Insurance Company for Coverage Extension
Subject: Request for Coverage Extension for Ongoing Cancer Treatment
July 15, 2025
Claims Department
HealthPlus Insurance
800 Insurance Boulevard
Chicago, IL 60601
To Whom It May Concern,
My name is Emily Chen, policy number HC-567890, and I am writing to request an extension of coverage for my ongoing cancer treatment.
Last year, I was diagnosed with Stage 2 breast cancer and have been undergoing treatment at Memorial Cancer Center under the care of Dr. Michael Robinson. My treatment plan includes chemotherapy, radiation, and possibly surgery, with an expected duration of 18 months.
According to my current policy, my cancer treatment coverage will expire on September 30, 2025, which is three months before my treatment plan is scheduled to complete. Discontinuing treatment would significantly reduce my chances of recovery and potentially allow the cancer to progress.
My oncologist has provided a detailed letter (attached) explaining the medical necessity of completing the full treatment course without interruption. Also attached are my recent medical records showing positive response to the current treatment protocol.
I have been a loyal customer of HealthPlus Insurance for over 12 years with minimal claims history. This situation is beyond my control, and I am asking for your compassion and support during this challenging time.
Thank you for your consideration. I hope you will approve this extension request so I can focus on healing rather than financial worries.
Respectfully,
Emily Chen
456 Oak Street
Chicago, IL 60607
Phone: (555) 789-0123
Email: emily.chen@email.com
3. Request to Employer for Medical Leave
Subject: Request for Extended Medical Leave
July 20, 2025
Ms. Patricia Rodriguez
Human Resources Manager
Tech Solutions Inc.
300 Corporate Way
San Francisco, CA 94105
Dear Ms. Rodriguez,
I am writing to formally request an extended medical leave from my position as Senior Software Developer at Tech Solutions Inc., starting August 15, 2025, for an estimated period of three months.
Recently, I was diagnosed with a herniated disc that requires surgery followed by extensive physical therapy. My doctor, Dr. James Wilson from Bay Area Medical Center, has advised that I will need this time to undergo the procedure and recovery process. The surgery is scheduled for August 18, 2025.
As per company policy, I understand that I am eligible for 12 weeks of medical leave under the Family and Medical Leave Act (FMLA). I have attached a medical certificate from Dr. Wilson detailing my condition and the expected recovery timeline.
During my absence, I suggest that my current projects can be temporarily managed by Alex Johnson and Sarah Thompson from my team, who are already familiar with the ongoing work. I am happy to help with the transition before my leave begins and will be available via email on a limited basis for any critical questions.
I greatly value my role at Tech Solutions and plan to return to full capacity once my recovery is complete. Thank you for your understanding and support during this challenging time.
Sincerely,
David Kim
789 Pine Avenue
Apartment 12C
San Francisco, CA 94110
Phone: (555) 234-5678
Email: david.kim@techsolutions.com
4. Request for Specialized Medical Equipment
Subject: Request for Specialized Wheelchair Approval
July 25, 2025
Medical Equipment Department
Medicare Services
1200 Healthcare Drive
Washington, DC 20001
Dear Medicare Services Representative,
My name is Margaret Johnson, Medicare ID number MED-123456789, and I am writing to request approval for a specialized motorized wheelchair as prescribed by my physician.
I am an 68-year-old woman with advanced multiple sclerosis that has significantly affected my mobility. My condition has worsened over the past six months, making it impossible for me to use my current manual wheelchair effectively. My doctor, Dr. Elizabeth Taylor at Washington Medical Center, has prescribed a Mobility Plus X500 motorized wheelchair that would allow me to maintain some level of independence.
The specific model has features that address my particular needs, including adjustable seating to prevent pressure sores, enhanced stability controls to accommodate my tremors, and a simplified control system that I can operate despite my limited hand dexterity. Standard motorized wheelchairs do not offer these crucial features.
I have attached the following documentation to support my request:
– Detailed prescription and medical necessity letter from Dr. Taylor – Recent medical records documenting the progression of my condition – Evaluation report from a physical therapist confirming my inability to use a manual wheelchair – Detailed quote for the Mobility Plus X500 from an approved supplier
Having access to this specialized equipment would significantly improve my quality of life and allow me to continue living at home rather than requiring institutional care, which would ultimately result in cost savings.
Thank you for your consideration of this request. Please contact me if you require any additional information.
With appreciation,
Margaret Johnson
567 Maple Lane
Washington, DC 20008
Phone: (555) 876-5432
Email: margaret.j@email.com
5. Request for Medical Records Transfer
Subject: Request for Complete Medical Records Transfer
August 1, 2025
Medical Records Department
Eastside Medical Center
400 Hospital Boulevard
Boston, MA 02108
Dear Medical Records Administrator,
This letter serves as a formal request to transfer my complete medical records from Eastside Medical Center to my new healthcare provider.
I am relocating to Denver, Colorado, next month and will be continuing my healthcare with Mountain View Medical Group. Please send all my medical information, including but not limited to examination notes, test results, imaging studies, treatment plans, and vaccination records covering my care from January 2020 to present.
Here is the information for my new healthcare provider:
Dr. Jennifer Martinez
Mountain View Medical Group
750 Health Parkway
Denver, CO 80202
Phone: (555) 987-6543
Fax: (555) 987-6544
Email: records@mountainviewmedical.com
I authorize the release of my complete medical file to Dr. Martinez and her medical practice. Please find attached a signed release form as required by HIPAA regulations.
Due to my upcoming appointment on September 15, 2025, I would appreciate if these records could be transferred by September 1, 2025.
Thank you for your prompt attention to this matter.
Sincerely,
Samuel Thompson
234 Commonwealth Avenue
Apartment 5D
Boston, MA 02116
Phone: (555) 345-6789
Email: samuel.t@email.com
Date of Birth: 03/12/1985
6. Appeal for Denied Medical Claim
Subject: Appeal for Denied Medical Claim #CLM-987654
August 5, 2025
Appeals Department
National Health Insurance
900 Claims Processing Center
Dallas, TX 75201
Dear Appeals Review Specialist,
This letter is a formal appeal regarding my denied medical claim #CLM-987654 for a CT scan performed on June 12, 2025, at Dallas Medical Center.
On July 20, 2025, I received a denial letter stating that the procedure was “not medically necessary.” However, this CT scan was specifically ordered by my neurologist, Dr. Andrew Wilson, after I experienced severe and persistent headaches for over three weeks, along with vision changes and balance problems.
Dr. Wilson suspected a possible brain tumor or aneurysm, conditions that require immediate investigation and can be life-threatening if left undiagnosed. The CT scan was the appropriate diagnostic tool given my symptoms and medical history of migraines.
I have attached the following documents to support my appeal:
– A detailed letter from Dr. Wilson explaining the medical necessity of the CT scan – My medical records showing the progression and severity of my symptoms – The radiologist’s report from the CT scan – The original claim and denial notice
The total amount in question is $2,850, which presents a significant financial hardship for me and my family. I have been a policyholder with National Health Insurance for over eight years and have always paid my premiums on time.
Please review this appeal carefully and reconsider your decision based on the medical necessity of this diagnostic procedure. I am happy to provide any additional information if needed.
Thank you for your time and consideration.
Respectfully,
Olivia Martinez
567 Lakeside Drive
Dallas, TX 75202
Phone: (555) 456-7890
Email: olivia.m@email.com
Policy Number: NHI-456789
7. Request for Second Medical Opinion Coverage
Subject: Request for Coverage of Second Medical Opinion
August 10, 2025
Dr. Richard Thompson
Medical Director
BlueStar Health Insurance
1100 Insurance Plaza
Philadelphia, PA 19103
Dear Dr. Thompson,
My name is James Wilson, policy number BS-789012, and I am writing to request coverage for a second medical opinion regarding my recent diagnosis of early-stage prostate cancer.
On July 25, 2025, my urologist, Dr. Paul Anderson at Philadelphia General Hospital, diagnosed me with Stage 1 prostate cancer based on biopsy results. He has recommended immediate radical prostatectomy as the treatment option.
Given the significant impact this surgery would have on my quality of life and the existence of alternative treatment approaches, I would like to consult with Dr. Susan Roberts, a specialist in prostate cancer at Johns Hopkins Medical Center, before making my final decision. Dr. Roberts is known for her expertise in less invasive treatment options that might be appropriate for my case.
My policy states that second opinions may be covered when the treatment involves major surgery or life-threatening conditions, both of which apply in my situation. The consultation with Dr. Roberts is scheduled for August 30, 2025, pending your approval.
I have attached my current medical records, pathology reports, and a referral letter from Dr. Anderson acknowledging the value of a second opinion in this case.
Thank you for considering my request. Getting expert advice before proceeding with such a significant medical decision would give me peace of mind during this stressful time.
Sincerely,
James Wilson
345 Cherry Street
Philadelphia, PA 19104
Phone: (555) 567-8901
Email: james.wilson@email.com
8. Request for Prescription Assistance Program
Subject: Application for Medication Assistance Program
August 15, 2025
Patient Assistance Program
PharmaCare Inc.
600 Pharmaceutical Way
Indianapolis, IN 46204
Dear Patient Assistance Program Coordinator,
I am writing to apply for your Medication Assistance Program for the prescription drug Cardiostat, which has been prescribed to me for my heart condition.
My cardiologist, Dr. Laura Bennett, has prescribed Cardiostat 25mg daily to manage my congestive heart failure. This medication has been effective in stabilizing my condition, but unfortunately, the monthly cost of $450 has become financially unsustainable for me.
My current situation:
– I am a 59-year-old retired school teacher living on a fixed income – My annual income is $24,000 from my pension – I do not qualify for Medicaid, and Medicare Part D still leaves me with a significant co-pay – I have no other prescription coverage – My monthly expenses for basic needs leave very little for medication costs
I have attached the completed application form, proof of income, a copy of my prescription, and a supporting letter from Dr. Bennett confirming the medical necessity of this medication for my survival and quality of life.
Your Medication Assistance Program would make a life-changing difference for me. Without this medication, my health would likely deteriorate rapidly, potentially resulting in hospitalization.
Thank you for considering my application. I hope to hear from you soon regarding my eligibility for this vital program.
Gratefully,
Barbara Anderson
789 Sunset Avenue
Indianapolis, IN 46205
Phone: (555) 678-9012
Email: barbara.a@email.com
9. Request for Specialist Referral
Subject: Request for Neurology Specialist Referral
August 20, 2025
Dr. Daniel Morris
Primary Care Physician
Westside Family Practice
250 Medical Park Drive
Seattle, WA 98101
Dear Dr. Morris,
I am writing to request a referral to a neurology specialist for ongoing symptoms that have not improved despite current treatment.
As you know from our recent appointments, I have been experiencing persistent migraines, numbness in my right arm, and occasional difficulty finding words for the past three months. The pain medication and lifestyle changes you recommended have provided minimal relief, and some symptoms seem to be worsening.
My symptoms are significantly affecting my daily life and work performance. As a software engineer, I spend long hours on the computer, which has become increasingly difficult due to these neurological issues.
Based on my research and discussions with my family, I believe a consultation with a neurologist would be beneficial to explore more specialized testing and treatment options. If possible, I would prefer a referral to the neurology department at Seattle Medical Center, as they are covered by my insurance plan.
My insurance provider, Pacific Health, requires a formal referral from my primary care physician before they will cover specialist visits. I have attached a copy of my insurance card and relevant policy information for your reference.
Thank you for your ongoing care and consideration of this request. I am available for any additional appointments or tests you might want to conduct before issuing the referral.
Best regards,
Nathan Parker
123 Evergreen Terrace
Seattle, WA 98102
Phone: (555) 789-0123
Email: nathan.p@email.com
Patient ID: WFP-345678
10. Request for Medical Bill Payment Plan
Subject: Request for Medical Bill Payment Plan Setup
August 25, 2025
Billing Department
County Hospital
700 Healthcare Boulevard
Austin, TX 78701
Dear Billing Department Representative,
I am writing regarding my outstanding medical bill #BL-123456 in the amount of $7,850 for my emergency appendectomy performed on July 5, 2025.
While I am grateful for the excellent care I received at County Hospital, paying this bill in full at this time would cause extreme financial hardship for my family. I recently had to take unpaid leave from work during my recovery, which has significantly impacted our household income.
I am requesting to set up a reasonable payment plan that would allow me to fulfill my financial obligation while maintaining basic living expenses for my family. Based on my current financial situation, I can commit to monthly payments of $350 until the bill is paid in full.
My proposed payment schedule would be:
– First payment of $350 on September 15, 2025 – Subsequent payments of $350 on the 15th of each month until the balance is paid – Final payment estimated for April 15, 2027
I understand this is a longer timeframe than your standard policy may allow, but I am committed to paying this debt completely. If this proposal is acceptable, please send me the necessary paperwork to formalize this arrangement.
I have attached a brief summary of my current income and essential expenses to demonstrate my financial situation. I appreciate your understanding during this difficult time.
Thank you for your consideration of this request.
Sincerely,
Michael Johnson
456 River Road
Austin, TX 78702
Phone: (555) 890-1234
Email: michael.j@email.com
11. Request for Accessible Healthcare Accommodation
Subject: Request for Accessible Medical Examination Accommodation
September 1, 2025
Dr. Rebecca Martinez
Office Manager
Cityview Medical Practice
350 Health Center Road
Portland, OR 97201
Dear Dr. Martinez,
I am writing to request specific accessibility accommodations for my upcoming annual physical examination scheduled for September 20, 2025, at 10:00 AM.
As a patient with multiple sclerosis who uses a wheelchair, I require certain accommodations to receive proper medical care. During my last visit to your facility, I encountered several challenges that made my examination difficult and uncomfortable.
The specific accommodations I am requesting include:
– An examination room with adequate space for wheelchair maneuverability – An accessible examination table that can be lowered to wheelchair height – Additional time allotted for my appointment to allow for slower transfers – Assistance from a trained staff member for safe transfers if needed
Under the Americans with Disabilities Act, medical facilities are required to provide reasonable accommodations to ensure equal access to healthcare services. These accommodations would allow me to receive the same quality of care as patients without mobility limitations.
I greatly appreciate the care I have received from Dr. Thompson over the years and would like to continue as his patient. Making these simple accommodations would significantly improve my healthcare experience.
Please contact me to confirm that these accommodations will be available for my upcoming appointment. If you have any questions or need additional information about my specific needs, please feel free to reach out.
Thank you for your attention to this matter.
Respectfully,
Lisa Rodriguez
789 Forest Avenue
Portland, OR 97202
Phone: (555) 901-2345
Email: lisa.r@email.com
12. Request for Expedited Medical Testing
Subject: Request for Urgent MRI Appointment
September 5, 2025
Scheduling Department
Advanced Imaging Center
800 Medical Parkway
Denver, CO 80202
Dear Scheduling Coordinator,
I am writing to request an expedited MRI appointment based on my doctor’s urgent recommendation.
My neurologist, Dr. Amanda Lewis at Denver Medical Group, has ordered an MRI of my brain after I experienced sudden vision changes and severe headaches over the past week. When calling to schedule this test, I was given an appointment for October 25, 2025, which is seven weeks from now.
Dr. Lewis has indicated that waiting this long could be dangerous given my symptoms and family history of aneurysms. She has marked the order as “urgent” but mentioned that a personal request from me might help expedite the process.
I understand that your facility manages many patients with serious conditions, but I am asking you to please consider my case for an earlier appointment due to the potentially serious nature of my symptoms. Dr. Lewis has offered to speak directly with your medical director if that would be helpful in assessing the urgency of my situation.
I am willing to take any cancelation appointment, even on short notice, and can make myself available at any time of day, including evenings and weekends.
I have attached the referral form from Dr. Lewis which details her concerns and the medical necessity for this timely imaging study.
Thank you for your understanding and assistance with this urgent health matter.
Sincerely,
William Chen
345 Mountain View Drive
Denver, CO 80203
Phone: (555) 012-3456
Email: william.c@email.com
13. Request for Home Healthcare Coverage
Subject: Request for Home Healthcare Services Coverage
September 10, 2025
Medical Review Board
SeniorCare Insurance
950 Elder Services Building
Miami, FL 33101
Dear Medical Review Board Members,
I am writing on behalf of my father, George Martinez, policy number SC-234567, to request coverage for home healthcare services following his discharge from Miami General Hospital scheduled for September 20, 2025.
My 79-year-old father was hospitalized on August 30, 2025, after suffering a stroke that has significantly affected his mobility and ability to perform daily activities independently. His treatment team, led by Dr. Sarah Johnson, has recommended 60 days of home healthcare services to ensure a safe recovery and prevent readmission.
The recommended home healthcare plan includes:
– Skilled nursing visits 3 times weekly for medication management and vital signs monitoring – Physical therapy sessions 2 times weekly for mobility and strength training – Occupational therapy 2 times weekly for activities of daily living training – Home health aide assistance 3 hours daily for personal care and safety supervision
According to his policy, which I have reviewed carefully, home healthcare services are covered when deemed medically necessary as an alternative to extended hospital stays or nursing home placement. The requested services would cost significantly less than continued hospitalization or nursing home care, making this not only the best option for my father’s recovery but also the most cost-effective solution.
I have attached the following documentation to support this request:
– Hospital discharge planning documents – Dr. Johnson’s detailed prescription for home healthcare services – Physical and occupational therapy assessments – Home safety evaluation report
My father has been a loyal policyholder with SeniorCare Insurance for over 15 years. His ability to return home safely depends on receiving these vital services.
Thank you for your prompt consideration of this request. Please contact me if you need any additional information.
Respectfully,
Carlos Martinez
Power of Attorney for George Martinez
678 Palm Avenue
Miami, FL 33102
Phone: (555) 123-4567
Email: carlos.m@email.com
14. Request for Medical Debt Forgiveness
Subject: Application for Medical Debt Forgiveness Program
September 15, 2025
Financial Assistance Department
United Medical Center
500 Healthcare Drive
Phoenix, AZ 85001
Dear Financial Assistance Coordinator,
I am writing to apply for your hospital’s Medical Debt Forgiveness Program regarding my outstanding medical bills totaling $35,750 from my emergency surgery and two-week hospitalization in June 2025.
As a single parent of two young children, I was already facing financial challenges when I experienced a sudden internal bleeding episode that required emergency surgery. Although I had health insurance through my employer, my policy had a high deductible and only covered 70% of the costs, leaving me with this overwhelming debt.
My current financial situation makes it impossible for me to pay this amount while maintaining basic needs for my family:
– My monthly income as a retail assistant manager is $2,800 – My monthly expenses for rent, utilities, food, and childcare total $2,600 – I have exhausted my savings during my unpaid medical leave – I am currently behind on several other bills due to this situation
I have attempted to set up a payment plan, but even the minimum payments would cause severe hardship and potential homelessness for my family. According to your hospital’s financial policy, patients experiencing extreme hardship may qualify for partial or complete debt forgiveness based on income and circumstances.
I have attached all required documentation for your program, including:
– Proof of income – Tax returns for the past two years – Bank statements – List of monthly expenses – Medical bills in question – Letter from my employer regarding my medical leave
Any assistance your program can provide would make an enormous difference in my family’s ability to recover from this medical and financial crisis. I am committed to paying what I can reasonably afford but need help to manage this unexpected burden.
Thank you for considering my application for this vital program.
Gratefully,
Jennifer Adams
123 Desert Flower Lane
Phoenix, AZ 85002
Phone: (555) 234-5678
Email: jennifer.a@email.com
Patient Account Number: UMC-456789
15. Request for Medical Transportation Assistance
Subject: Request for Medical Transportation Assistance
September 20, 2025
Community Services Coordinator
Senior Support Network
700 Elder Care Lane
Atlanta, GA 30301
Dear Community Services Coordinator,
My name is Harold Johnson, and I am an 83-year-old man requesting assistance with transportation to my regular medical appointments.
Since suffering a fall last month that resulted in a broken hip, I am no longer able to drive myself to my necessary medical appointments. I live alone and have no family members in the area who can provide regular transportation. Public transportation is not feasible due to my mobility limitations and the distance to my healthcare providers.
I have the following regular medical appointments:
– Orthopedic surgeon: Every two weeks on Mondays at 10:00 AM – Physical therapy: Three times weekly on Monday, Wednesday, and Friday at 2:00 PM – Primary care physician: Monthly on the first Thursday at 9:00 AM – Cardiologist: Every three months on the 15th at 11:00 AM
All appointments are at the Medical Arts Building at 500 Healthcare Boulevard, approximately 7 miles from my home at 890 Peachtree Street.
I understand that your organization provides transportation assistance to seniors in need through volunteer drivers and subsidized taxi services. Such assistance would be invaluable to me at this time, as missing these appointments could seriously impact my recovery and overall health.
My income is limited to Social Security benefits of $1,450 per month, making private transportation services financially out of reach. I can contribute a small amount toward the cost if required by your program guidelines.
I have attached a letter from my doctor confirming my medical need for these appointments and my current mobility limitations. I would be deeply grateful for any transportation assistance your organization can provide.
Thank you for your consideration and the valuable service you provide to seniors in our community.
Sincerely,
Harold Johnson
890 Peachtree Street
Apartment 12
Atlanta, GA 30302
Phone: (555) 345-6789
Email: harold.j@seniormail.com
Date of Birth: 05/12/1942
Wrapping Up: Letters for Medical Help
Writing an effective request for medical assistance can make all the difference in getting the help you need. These sample letters serve as starting points that you can customize to your specific situation. The key elements across all these examples include clearly stating your request, providing relevant details about your medical situation, explaining why assistance is needed, and including all necessary documentation.
When facing health challenges, reaching out for help shows strength, not weakness. A well-written request increases your chances of receiving the support you need during difficult times. Remember to keep copies of all correspondence and follow up if you don’t receive a response within a reasonable timeframe.
Your health is worth advocating for, and these letter templates give you the tools to do just that. With the right approach, you can navigate the healthcare system more effectively and focus on what truly matters—your recovery and wellbeing.