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

For an English Financial Assistance application and supporting documents, 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. UW Medicine will uphold the confidentiality and dignity of each patient. Any information submitted for consideration of financial assistance 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 financial obligations and information.

We want to help. Please submit your application promptly! You may receive bills until we get your information. UW Medicine and Seattle Cancer Care Alliance (SCCA) 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.