Tip for Charity Care (hospital-specific)

Many states have mandatory charity care laws that require hospitals to provide free or reduced-cost care to qualifying patients

Tip for Charity Care (hospital-specific)

Income thresholds vary but typically range from 200% to 400% of the Federal Poverty Level

Tip for Charity Care (hospital-specific)

Charity care eligibility is separate from Medicaid — you may qualify for charity care even if you do not qualify for Medicaid

Hospital & Providermoderate

Charity Care Application

Charity Care (hospital-specific) · Hospitals / Health Systems

Application for charity care or reduced-cost services at hospitals. Eligibility typically based on Federal Poverty Level guidelines. May cover full or partial balance forgiveness.

Form Details

Total fields: 40
Auto-fillable: 22 (55%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

🏢

Apply at the hospital's financial counseling office or billing department

📬

Mail the application to the hospital's charity care program

Filing Deadline

Varies by hospital and state. Many states mandate that hospitals accept applications for a minimum period after service (often 90-240 days). Apply before the bill goes to collections.

Required Attachments

📎 Completed charity care application (hospital-specific or state-mandated form)
📎 Proof of income and assets
📎 Proof of residency (some programs are limited to state residents)
📎 Insurance information (or documentation of uninsured status)
📎 Medical bills for the services in question

Processing Time

30-90 days for determination. Varies by hospital and complexity of the application.

What Happens Next

If approved, the hospital writes off some or all of the bill. The amount of relief depends on your income relative to the Federal Poverty Level (most programs cover patients at 200-400% FPL). You will receive a written determination.

Tips for This Form

✓ Many states have mandatory charity care laws that require hospitals to provide free or reduced-cost care to qualifying patients
✓ Income thresholds vary but typically range from 200% to 400% of the Federal Poverty Level
✓ Charity care eligibility is separate from Medicaid — you may qualify for charity care even if you do not qualify for Medicaid
✓ Ask for an itemized bill before applying — billing errors are common and you should only seek assistance for legitimate charges

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Financial Assistance Application (501(r) FAP)

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Hospitals / Health Systems or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.