Financial Assistance Application

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.

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

Financial Assistance Application Form – Confidential

Please fill out all information completely. If it does not apply, write “NA.” Attach additional pages if needed

SCREENING INFORMATION

Do you need an interpreter?
Has the patient applied for Medicaid?
May be required to apply before being considered for financial assistance
Does the patient receive state public services such as TANF, Basic Food, or WIC?
Is the patient currently homeless?
Is the patient’s medical care need related to a car accident or work injury?

PLEASE NOTE

  • We cannot guarantee that you will qualify for financial assistance, even if you apply.
  • Once you send in your application, we may check all the information and may ask for additional information or proof of income.
  • Within 14 calendar days after we receive your completed application and documentation, we will notify you if you qualify for assistance

PATIENT AND APPLICANT INFORMATION

Name
Untitled
MM slash DD slash YYYY
MM slash DD slash YYYY
Mailing Address
Employment status of person responsible for paying bill

FAMILY INFORMATION

List family members in your household, including you. “Family” includes people related by birth, marriage, or adoption who live together.
Name
Date of Birth
Relationship to Patient
If 18 years old or older: Employer(s) name or source of income
If 18 years old or older: Total gross monthly income (before taxes):
Also applying for financial assistance?
- Wages - Unemployment - Self-employment - Worker’s compensation - Disability - SSI - Child/spousal support - Work study programs (students) - Pension - Retirement account distributions - Other

INCOME INFORMATION

You must provide information on your family’s income. Income verification is required to determine financial assistance. All family members 18 years old or older must disclose their income. If you cannot provide documentation, you may submit a written signed statement describing your income. Please provide proof for every identified source of income. Examples of proof of income include:
  • A "W-2" withholding statement; or
  • Current pay stubs (3 months); or
  • Last year’s income tax return, including schedules if applicable; or
  • Written, signed statements from employers or others; or
  • Approval/denial of eligibility for Medicaid and/or state-funded medical assistance; or
  • Approval/denial of eligibility for unemployment compensation.
If you have no proof of income or no income, please attach an additional page with an explanation.

EXPENSE INFORMATION

We use this information to get a more complete picture of your financial situation.
Monthly Household Expenses:
(child support, loans, medications, other)

ASSET INFORMATION

This information may be used if your income is above 101% of the Federal Poverty Guidelines.
Does your family have these other assets?
Please check all that apply

ADDITIONAL INFORMATION

Please attach an additional page if there is other information about your current financial situation that you would like us to know, such as a financial hardship, excessive medical expenses, seasonal or temporary income, or personal loss.

PATIENT AGREEMENT

I understand that Columbia County Health System may verify information by reviewing credit information and obtaining information from other sources to assist in determining eligibility for financial assistance or payment plans. I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I give is determined to be false, the result may be denial of financial assistance, and I may be responsible for and expected to pay for services provided.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

For INQueries

If you have any questions or concerns, please contact our Quality Improvement Director at (509) 382-2531 x5570 or by emailing: janeti@cchd-wa.org

Columbia County Health System