If your family income is below 400 percent of the Federal Poverty Income Guidelines and you have high medical costs (exceeding 10 percent of your family income), you may qualify for full or partial financial assistance. Catastrophic medical coverage is also available for low-income, uninsured patients whose eligible medical bills exceed 30 percent of the patient’s annual family income. Our Patient Financial Services (PFS) office can determine whether you are eligible once you provide:

Your completed Financial Assistance Form and supporting documents should be returned to the PFS office. The PFS staff may contact you to request additional information. If you need assistance completing the form, please call our office. Once the eligibility process is complete, we will mail you a Financial Assistance Notification letting you know whether, and to what extent, you are eligible for financial assistance.

Additional payment options are available for those who do not qualify for financial assistance.