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Click ‘Get Form’ to open the PeaceHealth Financial Assistance Application Form in our editor.
Begin by filling out the Screening Information section. Indicate if you need an interpreter and whether the patient has applied for Medicaid.
In the Patient and Applicant Information section, provide details such as the patient's name, birth date, and contact information. Ensure all fields are completed accurately.
List family members in your household under the Family Information section. Include their names, dates of birth, and relationship to the patient.
Complete the Income Information section by providing proof of income for all family members aged 18 and older. Attach necessary documentation as specified.
Fill out the Asset Information section if applicable, detailing any additional assets that may affect eligibility.
Review all information for accuracy before signing and dating the form at the end. Make sure to keep a copy for your records.

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Versions	Form popularity	Fillable & printable
2023	4.5 Satisfied (35 Votes)
2016	4.5 Satisfied (67 Votes)
2014	4 Satisfied (27 Votes)

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Who qualifies for financial assistance for medical bills in California?

If your household income is at or below 300%, or in some regions up to 400%, of the federal poverty guidelines , you may be eligible. If youre experiencing high medical expenses as compared to your income, regardless of household income, you may be eligible.

Does HCA have financial assistance?

Expanded Charity Care Policy provides financial relief for emergency services to families with annual household incomes between 200% and 400% of FPG. For patients who qualify for this program, we cap their out-of-pocket balances at 4% of their annual income using a sliding scale.

Should I apply for hospital financial assistance?

Whether your income qualifies you for free care, discounts, or large bill relief, its always worth asking about your options. If you or someone you know is facing a medical bill they cant afford, start by: Searching for the hospitals financial assistance policy.

What do you say when asking for financial assistance?

Be honest and transparent: Explain your situation clearly and honestly. Share the reasons why you need financial help and how much you need. Be specific: Be clear about the amount you need and what you intend to use it for. Ask for help directly: Its important to be clear and direct about what you need.

What is DHS financial assistance?

Financial assistance is the transfer to a non-federal recipient anything of value for a public purpose, and at DHS includes grants, cooperative agreements, training, loans, direct payments, and flood insurance.