Financial Assistance Program
WORRIED ABOUT YOUR ABILITY TO PAY?



Please be prepared to include the following documents with your application:
- Past three months’ bank statements for all accounts.
- Latest Federal Income Tax Return, including W-2 Earnings Statements.
- Payroll check stubs, bank statements, or other documentation of monthly income, sources reflecting income, of all responsible parties for at least the three months prior to application.
- If applicable, please provide a statement of monthly benefit from Social Security or other retirement or disability benefits.
- Copies of rent or mortgage payments and utility bills.
- If applicable, please provide Medicaid/Medicare Approval/Denial Letter, Denial of Unemployment or Workers’ Compensation Benefits.
- Valid state issued identification, a utility bill received within the last 60 days, a lease agreement, vehicle registration card, or mail addressed to patient from a local State or Federal Government entity.
- Copies of any other supporting documentation you feel should be included.

After Submitting Your Application
We will send you a letter once your application has been reviewed and a determination is made.
For more information on Financial Assistance, please call Patient Financial Services at 1-800-994-0368 or email PFS@hshs.org.
For more information on Financial Assistance, please call Patient Financial Services at 1-800-994-0368 or email PFS@hshs.org.