Financial Assistance Application

To apply for financial assistance, please complete and submit the application found via the link below. A complete version of our Financial Assistance Policy is also available on this website. Copies of the application, plain language summary and complete policy can be obtained free of charge from a financial counselor at the hospital where care was received or requested by mail through the Patient Access Department of the hospital where care was received. These documents are also available in the language of any population consisting of ten percent or more of the community population the hospital serves.

Financial Assistance Application - English [112kb]

Financial Assistance Application - Spanish [39kb]