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Financial Assistance Application Form

Download the application form as a PDF

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 uwmedicine.org/financialassistance or valleymed.org/financialassistance.

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; 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)
  • 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

 

Harborview Medical Center

Financial Counseling

325 9th Ave
Mail Stop 359758

Seattle, WA 98104-2499

206.744.3084

FAX 206.744.5187

M-F 8:00 a.m.4:30 p.m.

 

UW Medical Center-Montlake

Financial Counseling

1959 NE Pacific Street
Mail Stop 356142

Seattle, WA 98195-6142

206.744.3084

FAX 206.598.1122

M-F 8:00 a.m. 4:30 p.m.

 

UW Medical Center-Northwest

Financial Counseling

1550 N 115th St
Seattle, WA 98133-9733

206.744.3084

M-F 8:00 a.m. – 4:30 p.m.

 

Harborview Medical Center
UW Medical Center

 

Patient Financial Services

 

10330 Meridian Ave. N Suite 260
S
eattle, WA 98133

 

206.598.1950 or 1.877.780.1121

 

M-F 8 a.m. – 4:30 p.m.

 

 

Valley Medical Center

 

Patient Financial Services

 

3600 Lind Ave SW, Suite 110
Renton,
WA 98057-4970

 

425.690.3578

 

FAX 425.690.9578

 

M-F 8:00 a.m. – 5:00 p.m.

 

 

UW Physicians
UW
Neighborhood Clinics

Patient Accounts & Inquiry

P.O. Box 50095
S
eattle, WA 98145-5095

206.520.9300 or 1.855.520.9300

FAX 206.520.3200

M-F 9:00 a.m. – 5:00 p.m.
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Harborview Medical Center
UW Medical Center

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.

Valley Medical Center

Patient Financial Services

P.O. Box 59148
Renton, WA 98058-2148

425.690.3578

FAX 425.690.9578

M-F 8:00 a.m. – 5:00 p.m.

Airlift Northwest

Patient Financial Services

6505 Perimeter Road S., Ste 200
Seattle, WA 98108

206.598.2912

FAX 206.521.1612

M-F 8:00 a.m. – 5:00 p.m.

 

If you have questions and need help completing this application please contact the facility above where you are seeking care. 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 get your information.