Financial Assistance Application


Instructions

This is an application for financial assistance (also known as charity care) at UW Medicine. Washington State requires all hospitals to provide financial assistance to people and families who meet certain income requirements. You may qualify for Financial Assistance based on your family size and income, even if you have health insurance. Assistance is awarded if you meet the Financial Assistance guidelines which includes your household income is 300% or less of the Federal Poverty Level. You can request more information or refer to our Financial Assistance website at www.uwmedicine.org/financialassistance / www.valleymed.org/financialassistance.

Download Financial Assistance Application (PDF)

What does financial assistance cover?

The hospital financial assistance covers appropriate hospital-based services provided by UW Medicine depending upon your eligibility. Financial assistance may not cover all health care costs, including services provided by other organizations.

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

Provide us information about your family

  • 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 & deductions)
  • Provide documentation for family income and declare assets
  • Attach additional information if needed, for example, letters of support to validate your information
  • Sign and date the 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 it will help speed up processing of your application. Social Security numbers are used to verify information provided to us. If you do not have a Social Security number, please mark “not applicable” or “NA.”

Submit your completed application with all documentation to the UW Medicine facility checked below. Be sure to keep a copy for yourself.

Airlift Northwest (Airlift)

Patient Financial Services
6505 Perimeter Road S., Ste 200
Seattle, WA 98108
206.965.1908 Fax 206.521.1612
M-F 8:00 a.m. – 5:00 p.m.

Harborview Medical Center (HMC)

Financial Counseling
325 9th Ave; Mail Stop 359758
Seattle, WA 98104-2499
206.744.3084
M-F 8:00 a.m. – 4:30 p.m.

UW Medical Center (UWMC)

Financial Counseling
1959 NE Pacific Street, Mail Stop 356142
Seattle, WA 98105-9950
206.598.3806
M-F 8:00 a.m. – 4:30 p.m.

HMC & UWMC

Patient Financial Services
P.O. Box 95459
Seattle, WA 98145-2459
206.598.1950 or 1.877.780.1121
FAX 206.598.2360
M-F 8:00 a.m. – 4:30 p.m.

Northwest Hospital & Medical Center (NWH)

Patient Financial Services
10330 Meridian Ave N Ste 260
Seattle, WA 98133-9851
206.668.6440 or 1.877.364.6440
M-F 8:00 a.m. – 4:30 p.m.

NWH Physicians

Patient Accounts & Inquiry
P.O. Box 45850
Seattle, WA 98145-0850
206.520.9100 or 1.855.520.9100
M-F 9:00 a.m. – 5:00 p.m.

UW Physicians (UWP) & UW Neighborhood Clinics (UWNC)

Patient Accounts & Inquiry
P.O. Box 50095
Seattle, WA 98145-5095
206.520.9300 or 1.855.520.9300
M-F 9:00 a.m. – 5:00 p.m.

Valley Medical Center (VMC)

Patient Financial Services
P.O. Box 59148
Renton, WA 98058-9900
425.251.5178 FAX 206.575.2573
M-F 8:00 a.m. – 5:00 p.m.

If you have questions and need help completing this application please contact the facility checked above. You may obtain help for any reason, including disability and language assistance.

We will notify you of the final determination of eligibility and appeal rights, if applicable, within 14 calendar 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.

We want to help. Please submit your application promptly!
You may receive bills until we receive your information.

Download Financial Assistance Application (PDF)