Financial Assistance Application Form

Washington State requires all hospitals to provide financial assistance to individuals 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. UW Medicine provides financial assistance for any patient/guarantor whose gross family income is up to 400% of the Federal Poverty Level (FPL) and adjusted for family size after any third-party coverage has been exhausted. For facility and/or professional services at Airlift Northwest, Harborview Medical Center, UW Medical Center, UW Physicians, UW Medicine Primary Care, and Valley Medical Center:

• 0% - 300% of the FPL for a 100% financial assistance discount

For facility services only with discharge dates on or after July 1, 2022 at Harborview Medical Center, UW Medical Center, and Valley Medical Center:

• 301% - 350% of the FPL for a 75% financial assistance discount
• 351% - 400% of the FPL for a 50% financial assistance discount

What does financial assistance cover? The financial assistance policy covers appropriate hospital-based (facility) and non-hospital-based (professional) services provided by UW Medicine depending upon your eligibility. Financial assistance may not cover all health care costs,including services provided by other organizations. You can request more information or refer to our website at uwmedicine.org/financialassistance uwmedicine.org/financialassistance.  

In order for your application to be processed, you must: Provide us information about your family tell us the number of family members in your household (family includes people related by birth, marriage, or adoption who live together)

• Provide your family’s gross monthly income (before taxes and deductions)
• Provide documentation for family income and provide a declaration of assets
• Attach additional information if needed, for example, letters of support to validate your information
• Sign and date the form

For the Financial Assistance Application and supporting documents in English, you can now utilize MyChart (except Airlift Northwest) to submit your documents based on your care location. For all other application submissions continue to submit by mail, fax, or in person. Any information submitted for consideration will be treated as protected health information under the Health Insurance Portability and Accountability Act (HIPAA).

To process your application, you must be a registered patient with a Medical Record Number (MRN):  For Harborview Medical Center, UW Medical Center – Montlake, UW Medical Center – Northwest, UW Physicians and UW Medicine Primary Care call the Contact Center at 206.520.5000 to register prior to completing your application.

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 the information.

We want to help. Please submit your application promptly! You may receive bills until we get your information. UW Medicine and Fred Hutchinson Cancer Center may share information if needed to help patients seeking care at both institutions (within 90-days of completing an application). If the application is approved by both institutions, the approval period may differ.