DOCUMENT OVERVIEW: This document may be used to release a patient from his/her financial
obligation.
[date]
[inside address]
Dear [name]:
[-‐ ] months have passed since we last heard from you regarding your outstanding medical
account balance.
We feel confident that if you could have paid this bill you would have done so. To reduce your
financial burden, we are not going to send you any more bills for payment due.
We only ask that when your financial situation improves, you remember us with your payment.
Sincerely,
[name]