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 AveMail Stop 359758Seattle, WA 98104-2499 206.744.3084FAX 206.744.5187 M-F 8:00 a.m. – 4:30 p.m. UW Medical Center-Montlake Financial Counseling 1959 NE Pacific StreetMail Stop 356142Seattle, WA 98195-6142 206.744.3084FAX 206.598.1122 M-F 8:00 a.m. – 4:30 p.m. UW Medical Center-Northwest Financial Counseling 1550 N 115th StSeattle, WA 98133-9733 206.744.3084 M-F 8:00 a.m. – 4:30 p.m. Harborview Medical CenterUW Medical Center Patient Financial Services 10330 Meridian Ave. N Suite 260Seattle, 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 110Renton, 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 Seattle, 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. Harborview Medical CenterUW Medical Center Patient Financial Services P.O. Box 95459Seattle, 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 59148Renton, 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 200Seattle, 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.