We want to get you the help you need. On this page, you'll find guidance on how to fill out your financial assistance application.
Start your application or get support completing it below.
How to Fill Out Your Financial Assistance Application
You can head directly to the sections you have questions about. Or start at the top, and we will walk you through the entire application. Do your best to fill out the application completely and accurately so we have a clear picture of your unique situation. We take your privacy seriously, and this information will remain safe, secure and confidential.
We ask for your contact information and employment status because each state provides different levels of assistance.
We consider your family’s size and unique income situation. Your “family” includes people related by birth, marriage, or adoption who live together.
When considering financial assistance eligibility, we will review your monthly income to help determine what assistance we can offer. We will ask you to provide us with certain items, such as paycheck stubs or tax return forms.
Financial Assistance Applications
Select the state where you received care to download the financial assistance application.
We believe that no one should delay seeking needed medical care because they lack health insurance or are worried about their ability to pay for their care.
Top Financial Assistance Application FAQs
A patient can apply for financial assistance at any point in their care journey with Providence. You can apply if you need help with medical bills you've already received or in anticipation of scheduled care.
Also, if you've been approved for financial assistance within the last 6 months, you don't need to reapply to get support for additional care. Call 855-229-6466 to discuss how we can extend your approval timeline. We want you to be able to focus on your health.
You’ll need to include the following information with your application—it’ s an industry standard to require this information to receive financial aid of any kind. If you don’t provide all of it, there may be a delay in processing your application. We understand this is sensitive information, and it is kept confidential.
Your most recent federal tax returns – Form 1040, and if self-employed, add Schedule C documentation.
Copies of the most recent income information for each person in the household such as pay stubs, Social Security, unemployment, retirement, pensions, etc. If you’re self-employed, please provide a 90-day profit and loss statement.
If the household is receiving financial support from family or friends, provide a letter detailing that support. If there is no income to report, please provide a letter of explanation. You may be asked to provide additional information, including but not limited to bank statements.
Note that you do not need a Social Security number to apply or qualify for financial assistance.
We understand it can feel like a lot of paperwork, but the information you provide is important. It helps us understand how we might support you better.
We ask for your contact information so we can provide a response, and we ask for your employment status so we know what documentation is needed. Need-based assistance is based on family size and income. That information helps determine what assistance we can offer. Occasionally we will review your monthly expenses to understand your financial situation better, which could include a mortgage, student loans or car financing, as well as other debt.
Your eligibility for financial assistance is based on your family size and income, and by your state’s eligibility requirements. We accept many different kinds of documents as proof of income, such as last year’s tax returns, W-2 forms, paystubs or even a letter from your employer.
If you're unemployed, you can submit proof or denial of unemployment benefits. If you're unable to provide proof of income or if you don’t have permanent housing, you can submit a letter explaining your income and living situation. We take everyone’s life circumstances into account when determining eligibility.
Though we’re exploring ways to make it easier for patients to check on the status of their financial assistance application, for now you’ll need to call us. It usually takes us 30 days (14 days in Washington) to process financial assistance applications. Then we’ll send a letter letting you know if you qualify for help and how much. We'll also let you know if additional information is needed to make a decision.