Financial Assistance Application - Washington
Download and Mail
- Request Online Application (English) – This will generate an email request for the online application.
The online form IS NOT designed to be used on a smart phone. Please use a tablet device or computer to access the form.
Using our online form requires that you attach documents such as income information. Please make sure that these documents are available on the device you use.
Proof of income is required. If you have no income, please attach a letter of explanation.
If you are unable to attach the required documents, please download the paper form and mail it and the required documents to:
PH&S Regional Business Office
P.O. Box 4227
Portland, OR 97208–3395
If you have any questions, please call us at:
Mon.–Fri. 8 a.m.–5:30 p.m. PT
We will respond to your request via mail within 14 business days of receiving it along with all required documents.
Download a list of providers who do and do not participate in financial assistance determination. Choose the hospital where you received or plan to receive care.
NOTE: Providers that do not follow the hospital’s financial assistance policy may have their own financial assistance policies, so please contact the provider directly if you have any questions regarding their policies.