Uw health financial assistance application: Fill out & sign online

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Click ‘Get Form’ to open the uwhealth org financial assistance document in the editor.
Begin by entering your name in the 'Applicant Name' field. Ensure you include your first, middle, and last names.
Provide your medical record number if known, and fill in the date of application.
Indicate whether you currently have insurance coverage by selecting 'Yes' or 'No'. If applicable, provide details about your coverage.
Complete the sections regarding your employment status, including employer information and income details. Be sure to list any dependents as well.
In the 'Certification' section, read through the statement carefully. You will need to sign and date this section electronically using our platform's 'Fill & Sign' tool.

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How do I get an estimate from UW Health?

About pricing transparency UW Health believes generating an estimate will provide a better value in understanding your potential out-of-pocket expenses. Please refer to UW Healths Price Estimate page on MyChart or by calling (608) 263-1507.

What does financial assistance cover?

FAPs must apply to all emergency and medically necessary care furnished by the hospital and substantially related entities. If emergency and medically necessary care is provided by the hospital facility, the care must be covered under the FAP. Check for a Provider List.

Who is eligible for UW financial aid?

be admitted to the University in an approved degree or certificate program (review your options for aid if you are a non-matriculated student). not have loans in excess of the aggregate limits of the aid programs. be making satisfactory academic progress towards a degree.

Who is eligible for UW financial assistance?

Are you eligible? 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.

uw financial assistance form

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Uwhealth org financial assistance 2026

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How to use or fill out uwhealth org financial assistance with our platform

Complete this form in 5 minutes or less

Got questions?

How do I get an estimate from UW Health?

What does financial assistance cover?

Who is eligible for UW financial aid?

Who is eligible for UW financial assistance?

Security and compliance

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Uwhealth org financial assistance 2026

Here's how it works

How to use or fill out uwhealth org financial assistance with our platform

Complete this form in 5 minutes or less

Got questions?

How do I get an estimate from UW Health?

What does financial assistance cover?

Who is eligible for UW financial aid?

Who is eligible for UW financial assistance?

uw financial assistance form

Security and compliance

uw health financial assistance form

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