"Let's make it right, together." 
The Consejo de Latinos Unidos

Our services are completely free.

The more information you provide, the better able we are to advise you in resolving your hospital bill. If you are unable to provide all of the information right now, please provide as much as you can.

Please complete all of the information below to the best of your ability.

First Name:
Last Name:
Home Phone:
Cell Phone:
Email Address:
Postal Address:
City:
State Abbreviation:
Zip Code:
Name & State of Hospital Where Treated:
Your Story:
Patient Date of Birth:
Date Admitted To Hospital:
Number of Days in Hospital:
How Much You Were Charged:
If Insured, the name of insurance:
Primary treatment you received:
By submitting the information above to HospitalVictims.org you agree to allow the Consejo de Latinos Unidos to use your information as deemed necessary by us for the purpose of fighting outrageous hospital prices. We will not share your information for any commercial purposes. Our services are completely free.
Notice: The Consejo de Latinos Unidos is only providing information. Such information is not legal advice. Legal advice can only come from a duly-licensed attorney in your State. The Consejo de Latinos Unidos encourages you to consult with an attorney on legal matters as there are time limits that could adversely affect your legal rights.