COVID-19: Vaccines, boosters, testing, and visitor guidelines. Please use ER for emergencies only. As significantly higher COVID surge looms, we ask for your help in preventing spread of the disease.

Financial Assistance Application

Choose a language to download the application:

Did you know you could sign up online?

Feel free to apply by going to My Peacehealth

Need help?

You can send us questions via My PeaceHealth or by contacting a Customer Service Representatives at 877-202-3597.

Sending in your completed application?

You can fax, email, or mail your completed applications to:





PO Box 748632
Los Angeles, CA 90074-8632

In person:

Applications may be taken to your local PeaceHealth Provider (In response to COVID, please check with your local provider before attempting to drop off)

Be sure to keep a copy for yourself.