Financial Assistance Application

Choose a language to download the application:

Need help?

For help completing the application, or to request free copies of our application form, please call a Customer Service Representative at 877-202-3597.

Sending in your completed application?

Mail complete applications to:

PeaceHealth
1115 SE 164th Ave., Dept 334 (FAP)
Vancouver, WA 98683

Or fax:

360-729-3047

In person:

Please contact Customer Service for the closest drop-off location at 877-202-3597.

Be sure to keep a copy for yourself.