Charity Care/Financial Assistance Application Form Instructions

This is an application for financial assistance (also known as charity care) at Providence.

Federal and state law requires all hospitals to provide financial assistance to people and families who
meet certain income requirements. You may qualify for free care or discounted care based on
your family size and income, even if you have health insurance. To view our financial assistance
policy and slide scale guidelines, please go to your residing state website from https://
www.providence.org/billing-support.

What does financial assistance cover? The medical financial assistance covers medically
necessary care provided by one of our hospitals or clinics within our family of organizations
depending upon your eligibility. Financial assistance may not cover all health care costs, including
services provided by other organizations.

If you have questions or need help completing this application: Our financial assistance policies,
information about the programs, and the application materials are available on our website or via phone.
You may obtain help for any reason, including disability and language assistance. Translated
written documents available upon request.
Here’s how to contact us: https://www.providence.org/billing-support
Customer Service Representatives at: 503-215-7575 or (+1) 855-229-6466
Monday-Friday 8:00 am to 5:00 pm

In order for your application to be processed, you must:

 Provide us information about your family
Fill in the number of family members in your household (family includes people related by birth,
marriage, or adoption who live together)
 Provide us information about your family’s gross monthly income (income before taxes and
deductions) to include pay stubs, W-2 forms, tax returns, social security awards letters, and
statements for income drawn from assets.1 (see financial assistance application Income Section
for more examples)
 Attach additional information if needed
 Sign and date the financial assistance form
Note: You do not have to provide a Social Security number to apply for financial assistance. If you
provide us with your Social Security number, your Social Security number may be used to identify you
or used to verify information provided to us. If you do not have a Social Security number, please mark
“not applicable” or “NA.”

Mail completed application with all documentation to: Providence Regional Business Office, P.O.
Box 31001-3422, Pasadena, CA UNITED STATES OF AMERICA. Be sure to keep a copy for
yourself.
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 To submit your completed application in person: Take to your nearest Hospital Financial Counselor's
Office. We will notify you of the final determination of eligibility and appeal rights, if applicable,
between 14 and 30 days of receiving a complete financial assistance application, including
documentation of income.

By submitting a financial assistance application, you give your consent for us to make necessary
inquiries to confirm financial obligations and information.

1 Except as may be prohibited by state law, Providence will collect and consider information related to
assets as required by the Centers for Medicare and Medicaid Services (CMS) for Medicare cost reporting.
This applies specifically to Medicare beneficiaries who do not also have Medicaid insurance. For all others,
asset information is optional.

506318055.3

We want to help. Please submit your application promptly. You may continue to receive billing
statements until we receive your completed application and required documentation unless
prohibited by your state's charity care laws.

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 Charity Care/Financial Assistance Application Form – confidential
Please fill out all information completely. If it does not apply, write “NA.” Attach additional pages if needed.

SCREENING INFORMATION
Do you need an interpreter? □ Yes □ No If Yes, list preferred language:
Has the patient applied f or Medicaid? □ Yes □ No Is the patient Blind? □ Yes □ No Is the patient Disabled?
□ Yes □ No
Does the patient receive state public services such as TANF, Basic Food, or WIC? □ Yes □ No
Is the patient currently homeless? □ Yes □ No
Is the patient’s medical care need related to a car accident or work injury? □ Yes □ No
N PLEASE NOTE
• We cannot guarantee that you will qualify for financial assistance, even if you apply.
• Once you send in your application, we may check all the information and may ask for additional information
or proof of income.
• Within 14-30 days after we receive your completed application and documentation, we will notify you of our
determination.
PATIENT AND APPLICANT INFORMATION
Patient first name Patient middle name Patient last name

□ Male □ Female Birth Date Patient Social Security Number

□ Other (may specify ) (optional)

Person Responsible for Paying Bill Relationship to Birth Date Social Security Number (optional)
Patient

Mailing Address Main contact number(s)

( )
( )
Email Address:
City State Zip Code
Country

Employment status of person responsible for paying bill

□ Employed (date of hire): □ Unemployed (how long unemployed:)

□ Self-Employed □ Student □ Disabled □ Retired □ Other

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507846221.4
 Charity Care/Financial Assistance Application Form – confidential
FAMILY INFORMATION
List family members in your household, including you. “Family” includes people related by birth, marriage, or
adoption who live together.
FAMILY SIZE Attach additional page if needed

Date If 18 years old or If 18 years old or

Also applying
Name Relationship to older: older: Total gross
of Patient Employer(s) name monthly for financial
or source of income (before assistance?
Birth taxes):
income
Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

All adult family members’ income must be disclosed. Sources of income include, for example:
Wages- Unemployment-Self-employment-Worker’s Compensation-Disability-SSI-Child/spousal support-Work
study programs (students)- Income drawn from assets for example-stocks, bonds, IRAs, mutual funds, rental
income, etc.

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 Charity Care/Financial Assistance Application Form – confidential

INCOME INFORMATION
REMEMBER: You must include proof of income with your application.
You must provide information on your family’s income. Income verification is required to determine
financial assistance. All family members 18 years old or older must disclose their income. If you cannot
provide documentation, you may submit a written signed statement describing your income. Please
provide proof for every identified source of income.
Examples of proof of income include:
• A "W-2" withholding statement; or
• Current pay stubs (3 months); or
• Last year’s income tax return, including schedules if applicable; or
• Written, signed statements from employers or others; or
• Statements of income drawn from assets (stocks, bonds, IRAs, mutual funds, etc); or
• Approval/denial of eligibility for unemployment compensation.
If you have no proof of income or no income, please attach an additional page with an explanation.
EXPENSE INFORMATION
We use this information to get a more complete picture of your financial situation.
Monthly Essential Living Expenses:
Rent/mortgage $ Medical expenses $
Medical Insurance Premiums $ Utilities $
Other Debt/Expenses $ (child support, loans, medications, other)
ASSET INFORMATION AND DOCUMENTATION

Current checking account balance Does your family have these other assets? Please check all that
(See below to see if you need to apply
provide a bank statement*)
$ □No Assets
□ Stocks □ Bonds □ 401K □ Health Savings Account(s)
General savings account balance
$

For Medicare beneficiaries without Medicaid insurance, Providence may ask for bank statements or similar

source documentation.

*This information is required only from Medicare beneficiaries who do not also have Medicaid
insurance. For all others, this information is optional. This information may only be used in
accordance with our policy and the State regulations in which you received care and is
collected and considered as required by the Centers for Medicare and Medicaid Services
(CMS) for Medicare cost reporting.

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 ADDITIONAL INFORMATION

Please attach an additional page if there is other information about your current financial
situation that you would like us to know, such as a financial hardship, excessive medical
expenses, seasonal or temporary income, or personal loss.

PATIENT AGREEMENT

I understand that Providence may verify information by reviewing credit information and obtaining information
from other sources to assist in determining eligibility for financial assistance or payment plans.

I affirm that the above information is true and correct to the best of my knowledge. I understand if the
financial information I give is determined to be false, the result may be denial of financial assistance, and I
may be responsible for and expected to pay for services provided.

Signature of Person Applying Date

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