Financial Assistance Application

 

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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. Assistance is awarded if you meet the Financial Assistance guidelines which includes your household income is 300% or less of the Federal Poverty Level. You can request more information or refer to our Financial Assistance website at www.uwmedicine.org/financialassistance or https://www.valleymed.org/financialassistance.

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.

 
Harborview Medical Center
UW Physicians 
UW Neighborhood Clinics  
Financial Counseling
325 9th Ave; Mail Stop 359758
Seattle, WA 98104-2499
Phone 206.744.3084
FAX 206.744.5187
M-F 8:00 a.m. – 4:30 p.m.
mychart.uwmedicine.org   

 
UW Medical Center-Montlake    
UW Physicians 
UW Neighborhood Clinics  
Financial Counseling
1959 NE Pacific Street
Mail Stop 356142
Seattle, WA 98195-6142
Phone 206.744.3084
FAX 206.598.1122
M-F 8:00 a.m. – 4:30 p.m.
mychart.uwmedicine.org   

 
UW Medical Center-Northwest 
UW Physicians 
UW Neighborhood Clinics  
Financial Counseling
1550 N 115th St
Seattle, WA 98133-9733
Phone 206.744.3084
FAX 206.598.1122
M-F 8:00 a.m. – 4:30 p.m. 
 mychart.uwmedicine.org  

 
Valley Medical Center 
Patient Financial Services 
P.O. Box 59148
Renton, WA 98058-2148  
Phone 425.690.3578 
FAX 425.690.9578
M-F 8:00 a.m. – 5:00 p.m 
mychart.valleymed.org/#mychart    

 

 
Valley Medical Center 
Patient Financial Services
3600 Lind Ave SW, Suite 110
Renton, WA 98057-4970
Phone 425.690.3578
FAX 425.690.9578
M-F 8:00 a.m. – 5:00 p.m.
mychart.valleymed.org/#mychart 

 
Airlift Northwest    
 Patient Financial Services
6505 Perimeter Road S., Ste 200
Seattle, WA 98108
Phone 206.598.2912
FAX 206.521.1612
M-F 8:00 a.m. – 5:00 p.m.

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.

We want to help. Please submit your application promptly!
You may receive bills until we receive your information.