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Medicine financial assistance application 2025

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4.8 out of 5

259 votes

The document provides instructions for applying for financial assistance (charity care) at UW Medicine, detailing eligibility criteria based on family size and income, which must be 300% or less of the Federal Poverty Level. It outlines the necessary information and documentation required for application processing, including family details, income verification, and asset information. The document also specifies where to submit the application and emphasizes that assistance may not cover all healthcare costs. Additionally, it includes contact information for various UW Medicine facilities for further inquiries.

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Click ‘Get Form’ to open the medicine financial assistance application in the editor.
Begin by filling out the 'Patient and Applicant Information' section. Include the patient's full name, date of birth, and contact details. If applicable, provide the Social Security number.
In the 'Family Information' section, list all family members living in your household. Ensure you include their names, dates of birth, and relationship to the patient.
Complete the 'Income Information' section by detailing each family member's gross monthly income. Attach necessary documentation such as pay stubs or tax returns for verification.
Fill out the 'Expense Information' section to provide a clear picture of your monthly household expenses including rent, medical expenses, and other debts.
Review all sections for accuracy before signing and dating the form at the end. Ensure that you have attached any additional information required.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (259 Votes)
2016	4 Satisfied (46 Votes)

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