Financial Assistance Application

Instructions

• This is an application for financial assistance (also known as charity care) at UW Medicine | Valley Medical Center. Washington State requires all hospitals to provide financial assistance to people and families who meet certain income requirements. You may qualify for Financial Assistance based on your family size and income, even if you have health insurance. UW Medicine / Valley Medical Center provides financial assistance for any patient/guarantor whose gross family income is up to 400% of the Federal Poverty Level (FPL) and adjusted for family size after any third-party coverage has been exhausted. For facility and/or professional services at Airlift Northwest, Harborview Medical Center, UW Medical Center, UW Physicians, UW Medicine Primary Care, and Valley Medical Center: You can request more information or refer to our Financial Assistance website at www.uwmedicine.org/financialassistance or http://lak.16300a.com/financialassistance.
  
  
• 0% - 300% of the FPL for a 100% financial assistance discount
  
  
• For facility services only with discharge dates on or after July 1, 2022 at Harborview Medical Center, UW Medical Center, and Valley Medical Center:
  
  
  • 301% - 350% of the FPL for a 75% financial assistance discount
  • 351% - 400% of the FPL for a 50% financial assistance discount

What does financial assistance cover?

The hospital financial assistance covers appropriate hospital-based services provided by UW Medicine | Valley Medical Center depending upon your eligibility. Financial assistance may not cover all health care costs, including services provided by other organizations.

In order for your application to be processed, you must:

• Provide us information about your family; fill in the number of family members in your household (family includes people related by birth, marriage, or adoption who live together)
• Provide us information about your family’s gross monthly income (income before taxes & deductions)
• Provide documentation for family income and declare assets
• Attach additional information if needed, for example, letters of support to validate your information
• Sign and date the form

For an English Financial Assistance application and supporting documents, you can now utilize MyChart (except Airlift Northwest) to submit your documents based on your care location. For all other application submissions continue to submit by mail, fax, or in person. UW Medicine will uphold the confidentiality and dignity of each patient. Any information submitted for consideration of financial assistance will be treated as protected health information under the Health Insurance Portability and Accountability Act (HIPAA).

Note: 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.”

Submit your completed application with all documentation to the UW Medicine facility where you are seeking care. Be sure to keep a copy for yourself.

If you have any questions and need help completing this application, please contact the facility above where you are seeking care. You may obtain help for any reason, including disability and language assistance. We will notify you of the final determination of eligibility and appeal rights, if applicable, within 14 calendar days of receiving a complete financial assistance application, including documentation of income. By submitting a financial assistance application, you give your consent for us to make necessary inquiries to confirm financial obligations and information.