Use when a non-profit (501(c)(3)) hospital is engaging in conduct inconsistent with its charitable purpose: failing to honor its Financial Assistance Policy under IRS § 501(r), pursuing extraordinary collection action without screening for FAP eligibility, billing at chargemaster while reporting community benefit on Schedule H, or filing hospital liens for amounts above the contracted rate.
IRS Form 13909 (Tax-Exempt Organization Complaint Referral) is the federal pathway for reporting these patterns. The IRS does not typically revoke 501(c)(3) status over a single complaint, but it does add the complaint to the file used for the organization's next audit cycle, can trigger follow-up correspondence with the hospital, and creates a public record that strengthens any state-DOI / state-AG complaint filed in parallel.
This template generates the narrative attachment that goes with Form 13909. The form itself is one page (downloadable at irs.gov; search "Form 13909"); the IRS gives little space on the form for facts, so the substantive case lives in the attachment.
[PATIENT FULL NAME]
[STREET ADDRESS]
[CITY, STATE ZIP]
Phone: [PATIENT PHONE]
Email: [PATIENT EMAIL]
[DATE]
INTERNAL REVENUE SERVICE
EO Examinations Classification Office
1100 Commerce Street, MC 4910 DAL
Dallas, TX 75242
[Or fax to 214-413-5415]
VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED
USPS Tracking: [CERTIFIED MAIL TRACKING NUMBER]
cc by certified mail:
[STATE] Attorney General, Charitable Organizations Division
[STATE] Department of Insurance, Consumer Services
[HOSPITAL BOARD CHAIR, see Form 990 Part VII], courtesy notice
RE: Form 13909 referral and supporting narrative,
Subject organization: [HOSPITAL LEGAL NAME], EIN [EIN]
Most recent IRS Form 990 reviewed: fiscal year [YEAR], filed [DATE]
Complainant: [PATIENT FULL NAME]
Conduct period: [DATE RANGE]
Account in dispute: [ACCOUNT NUMBER]
To EO Examinations Classification:
I am filing a Form 13909 complaint referral against [HOSPITAL LEGAL NAME], EIN [EIN], for conduct inconsistent with its obligations under 26 U.S.C. § 501(r) and inconsistent with the charitable-purpose representations on its IRS Form 990. The Form 13909 itself is enclosed; this letter is the supporting narrative.
I. Subject organization and exemption status
[HOSPITAL LEGAL NAME] is a tax-exempt § 501(c)(3) organization operating [N] hospital facilities in [STATE(S)]. Its most recent IRS Form 990 (fiscal year [YEAR], filed [DATE]) is publicly available on ProPublica Nonprofit Explorer and on the IRS Tax Exempt Organization Search.
Per the most recent Schedule H, the organization reported:
- Part I, Line 7a (Financial Assistance at Cost): $[CHARITY CARE NUMBER]
- Part I, Line 7e (Net Community Benefit Expense): $[CB EXPENSE]
- Part I, Line 7g (Bad Debt): $[BAD DEBT]
- Total revenue (Form 990 Part I, Line 12): $[TOTAL REVENUE]
- CEO total compensation (Form 990 Part VII): $[CEO COMP]
Per Schedule H Part V Section B (Facility Policies and Practices), the organization represented to the IRS that it [DOES / DOES NOT] have a written FAP, [DOES / DOES NOT] have an Emergency Medical Care Policy, and [DOES / DOES NOT] make reasonable efforts to determine FAP eligibility before extraordinary collection action.
II. Specific conduct at issue
[The complainant renders one or more of the blocks below based on what they experienced.]
[BLOCK A, FAP screening failure under § 501(r)(6)]
On [DATE], I received care at [HOSPITAL FACILITY]. The total billed amount was $[BILLED]. The organization's published FAP, available at [URL], states that patients at or below [N]% of the federal poverty level are eligible for full financial assistance. My household income at the time of service was $[INCOME], for a household of [N] persons, putting me at approximately [N]% of FPL, within the published eligibility tier.
The organization did not, at any point before or during my visit, provide me with a plain-language summary of the FAP, an application form, or a screening for eligibility. After the visit, I received [N] statements at the chargemaster amount of $[BILLED] without any mention of the FAP. I subsequently applied for FAP on my own initiative on [DATE], a copy of which is attached as Exhibit A.
Treasury Regulation § 1.501(r)-6(c) requires the organization to make "reasonable efforts to determine whether an individual is FAP-eligible before engaging in extraordinary collection actions". The organization did not make reasonable efforts in my case.
[BLOCK B, Extraordinary collection action without FAP determination]
The organization referred my account to [COLLECTION AGENCY NAME] on [DATE] without first determining my FAP eligibility, in apparent violation of Treasury Regulation § 1.501(r)-6(c). The referral occurred [N] days after the first post-discharge statement. The published FAP's stated minimum notification period is [N] days; the organization did not honor its own published notification period.
[BLOCK C, Charging FAP-eligible patients above amounts generally billed]
Treasury Regulation § 1.501(r)-5 requires the organization to limit amounts charged to FAP-eligible patients to "amounts generally billed" (AGB) to insured patients. The organization charged me $[BILLED], which, on a code-by-code basis using the organization's own machine-readable file published under 45 CFR Part 180, exceeds the lowest payer-specific negotiated rate by [N]x. A copy of the relevant lines from the organization's MRF, retrieved [DATE], is attached as Exhibit B.
[BLOCK D, Hospital lien filed at chargemaster, violating § 1.501(r)-6 and state lien law]
The organization filed a statutory hospital lien against my tort recovery at the chargemaster amount of $[LIEN AMOUNT] on [DATE LIEN FILED], notwithstanding (a) the contracted commercial rate on my EOB of $[EOB ALLOWED] and (b) the patient's eligibility for FAP. A lien at chargemaster, when the underlying account is FAP-eligible, exceeds AGB and is an extraordinary collection action subject to § 501(r) restrictions. A copy of the recorded lien is attached as Exhibit C.
[BLOCK E, Schedule H representations inconsistent with practice]
The organization's Schedule H Part V Section B (Question [N]) responded "Yes" to: "Has the facility made reasonable efforts to determine FAP eligibility before engaging in extraordinary collection action?" This response is materially inconsistent with the conduct described in Block A / B / C / D above. The Schedule H Section B answers are sworn declarations to the IRS; a "Yes" answer combined with conduct that contradicts it is itself a misrepresentation that supports examination.
[BLOCK F, Misstatement of community benefit]
The organization reported $[CB EXPENSE] in net community benefit on Schedule H Part I, Line 7e. A material portion of that number consists of bad debt the organization tried to collect from individual patients (Schedule H Part I, Line 7g: $[BAD DEBT]) and Medicaid shortfalls. The patient-direct charity-care figure (Part I, Line 7a) is $[CHARITY CARE NUMBER], or [N]% of total revenue. For a tax-exempt hospital serving [SERVICE AREA] with [HOSPITAL CHARACTERISTICS], this allocation may not satisfy the "community benefit standard" required to maintain exemption.
III. Documents enclosed
A, IRS Form 13909 (signed)
B, Copy of [HOSPITAL FACILITY]'s published Financial Assistance Policy from [URL], retrieved [DATE]
C, Copy of the disputed bill, account [ACCOUNT NUMBER]
D, Copy of the EOB, claim [CLAIM NUMBER]
E, Copy of [HOSPITAL]'s machine-readable file excerpt for the codes billed (per 45 CFR Part 180), retrieved [DATE]
F, Copy of [HOSPITAL]'s Schedule H (Form 990) for fiscal year [YEAR]
G, Copy of any collection-agency notices or hospital-lien filings
H, Copy of my FAP application dated [DATE], if filed
I, Certified-mail tracking for prior correspondence with the hospital
IV. Relief requested
I respectfully request that the EO Examinations Office:
1. Open an examination of [HOSPITAL LEGAL NAME] under Form 13909 procedures.
2. Verify compliance with the four enumerated § 501(r) requirements:
(a) Community Health Needs Assessment under § 501(r)(3);
(b) Financial Assistance Policy under § 501(r)(4);
(c) Limitation on charges to FAP-eligible patients under § 501(r)(5);
(d) Billing and collection practices under § 501(r)(6).
3. Where non-compliance is found, take appropriate corrective action, which may include private letter ruling, public listing, or, in cases of substantial and continued non-compliance, revocation of § 501(c)(3) status under § 501(r)(7).
4. Provide me with confirmation of receipt of this complaint and, when permitted by federal disclosure rules, a summary of any action taken.
V. Authorization
I authorize the Internal Revenue Service to share this complaint and supporting documentation with the subject organization for purposes of investigation and response. I authorize the [STATE] Attorney General and [STATE] Department of Insurance to coordinate with the IRS on this matter to the extent permitted by federal disclosure rules.
I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct to the best of my knowledge.
Executed on [DATE] at [CITY], [STATE].
[PATIENT FULL NAME]
Date of birth: [DOB]
Address: [STREET ADDRESS, CITY, STATE ZIP]
Phone: [PATIENT PHONE]
Email: [PATIENT EMAIL]
- The drafter renders only the blocks (A-F) that apply, drawing from the bill's
findingsfield and the action log. Most complaints will use one or two blocks. [EIN],[CEO COMP], and other 990-specific values come from ProPublica Nonprofit Explorer at projects.propublica.org/nonprofits or from GuideStar. Seereferences/irs_990_review.mdfor the lookup walkthrough.- The IRS Form 13909 itself is one page and fillable from the IRS website. The kit does not bundle the PDF; the patient downloads it, fills it in, and mails or faxes it with this narrative attached.
The drafter confirms:
- The hospital is in fact a tax-exempt § 501(c)(3) entity. Verify with the IRS Tax Exempt Organization Search. For-profit hospitals are subject to other consumer-protection law but not § 501(r).
- At least one of Blocks A-F has documentary support. A Form 13909 without specifics is unlikely to receive serious review.
- The patient has already pursued the hospital directly through the kit's normal dispute flow. Form 13909 is parallel pressure, not a substitute for the dispute letter to the hospital itself.
- File a state AG charitable-organizations complaint. Most states' attorneys general supervise charitable organizations under state law parallel to the federal § 501(c)(3) framework.
- File a CMS Hospital Price Transparency complaint at cms.gov/hospital-price-transparency/contact-us if any of the conduct involves MRF non-compliance.
- File a state DOI complaint via
templates/complaint_state_doi.md, Category F (HPT non-compliance) or other applicable category. - If the conduct includes credit reporting of the disputed account, file the FCRA dispute via
templates/letter_credit_report_dispute_fcra.md.
- IRS Form 13909 typically does not produce a substantive response within any specific window. The complaint is added to the EO Examinations file for the organization. Expect months-to-years before any visible effect.
- The state AG and DOI complaints typically produce a response within 30-90 days and are the faster pressure track. Do not wait for the IRS to act before pursuing state-level relief.
- If the hospital reaches out to settle as a result of the parallel pressure, evaluate whether to withdraw the Form 13909 as part of the settlement (most patients do not, because the public-record value of the filing matters beyond the individual case).
templates/letter_hardship_negotiation.md, primary FAP-eligibility letter to the hospital.templates/letter_financial_assistance_application.md, formal FAP application.templates/letter_challenge_hospital_lien.md, when a lien is involved.references/irs_990_review.md, how to read the hospital's Form 990 / Schedule H.references/medical_debt_protection_by_state.md, state charity-care-screening statutes that may parallel § 501(r).