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?

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

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

Fax:

360-729-3047

Email:

financialassistance@peacehealth.org

In person:

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

Be sure to keep a copy for yourself.