Subject: Notification that the payment cap has been reached and request for
a free card

I hereby notify you that the payment cap under section 6 a of the Act on
Client Charges in Healthcare and Social Welfare (734/1992) has been reached
in my case during the calendar year [YEAR].

Client fees counting towards the cap that I have paid: a total of [SUM]
euros; an itemisation and receipts are attached. The annual payment cap has
therefore been exceeded.

I request a certificate that the payment cap has been reached (a free card)
and a refund of the fees charged in excess of the cap.

[DATE]
[FIRST NAME LAST NAME, PERSONAL IDENTITY CODE, ADDRESS]