Disapproval Memo Example

Financial Operations

(J-8)

DEFENSE HEALTH AGENCY

7700 ARLINGTON BOULEVARD, SUITE 5101

FALLS CHURCH, VIRGINIA 22042-5101

SAMPLE TEXT FOR DISAPPROVED DISCOUNT AND/OR WAIVER REQUESTS

[Date]

John P. Doe

123 Anystreet

Anytown, VA 12345

Dear Mr. Doe,

Thank you for applying to the Military Health System Modified Payment and Waiver Program. We have reviewed your application and based on the information you have provided; we have determined that you are not eligible for a [waiver or discount] of your medical bill at this time. If your financial circumstances change, you may reapply to the program by submitting another application.

If you have any questions or wish to discuss this matter with our representative, please contact us at (703) 681-xxxx. Thank you.

[SIGNATURE BLOCK]