Charity Care/Financial Assistance Application Form Instructions
This is an application for financial assistance (also known as Charity Care) at Columbia County Health System.
Washington State requires all hospitals to provide financial assistance to people and families who meet certain income requirements. You may qualify for free care or reduced-price care based on your family size and income, even if you have health insurance.
What does financial assistance cover? The hospital financial assistance covers appropriate hospital-based services provided by Dayton General Hospital, Columbia Family Clinic and Waitsburg Clinic depending upon your eligibility. Financial assistance may not cover all health care costs, including services provided by other organizations.
If you have questions or need help completing this application: Please contact the Columbia County Health System Business Office at 1012 S 3rd Street in Dayton, WA or (509)382-2531. You may obtain help for any reason, including disability and language assistance.
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 and deductions)
- Provide documentation for family income and declare assets
- Attach additional information if needed
- Sign and date the form
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.”
Complete the form below and click submit. You will receive an email to submit your supporting documents.
You can also Mail or fax completed application with all documentation to: Columbia County Health System/1012 S 3rd Street/Dayton, WA 99328, FAX: 509.382.3210. Be sure to keep a copy for yourself.
To submit your completed application in person: Columbia County Health System Business Office, Monday through
Friday from 7:30am to 5:00pm and Saturday from 8:00am to 2:00pm.
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.