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Request Financial Assistance

Applying for Financial Assistance

Patients may apply for Financial Assistance before, during, or after treatment. Download and print the application and instructions. You also can get one by visiting Patient Financial Services or by calling Customer Service. See our frequently asked questions for more information.

Applications must include income verification in order to be evaluated.

You do not have to provide a social security number to apply for financial assistance. If you provide us with your Social Security number it will help speed up processing of your application. Social Security numbers are used to verify information provided to us. If you do not have a Social Security number, please mark "not applicable" or "NA."

Consideration of an application occurs when the application with income information is received by PeaceHealth in accordance with the PeaceHealth Financial Assistance Policy and Financial Assistance Procedure. The financial assistance allowance structure is based on Federal Poverty Guidelines adjusted for family size and location, which are available on the U.S. Department of Health & Human Services website.

Financial assistance from PeaceHealth is secondary to financial resources available to the patient, including, but not limited to: insurance, third-party liability, government benefits, support from community agencies, and/or personal resources.

Financial Assistance is granted only for medically necessary evidenced-based care or for urgent or emergent services. No patient will be denied care due to inability to pay. Consideration may be given for preventive screening on a case-by-case basis.

For complete information about Financial Assistance, click here

Send applications for financial assistance to:

PO Box 748632
Los Angeles, CA 90074-8632

Financial Assistance Plain Language Summary

The Plain Language Summary includes a brief explanation of financial assistance offered by PeaceHealth including eligibility requirements, where and how to get information, where to apply, contact information for additional assistance, available translations and other important notices regarding limitations on billing. Choose a language to download the Plain Language Summary

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

Financial Assistance Policies and Procedures

The following Policy and Procedure documents provide information about Financial Assistance programs offered by PeaceHealth that assist patients, provide medical management, and support the financial stability of PeaceHealth.