Tip for FAP Application (hospital-specific)

All 501(c)(3) nonprofit hospitals are REQUIRED to have a Financial Assistance Policy — ask for it if not offered

Tip for FAP Application (hospital-specific)

Apply even if you have insurance — high deductibles and out-of-pocket costs may still qualify you for assistance

Tip for FAP Application (hospital-specific)

Hospitals cannot charge FAP-eligible patients more than the amounts generally billed to insured patients

Hospital & Providermoderate

Financial Assistance Application (501(r) FAP)

FAP Application (hospital-specific) · 501(c)(3) Nonprofit Hospitals

Application for charity care / financial assistance based on income and family size. Under IRS Section 501(r), nonprofit hospitals must have a written Financial Assistance Policy, widely publicize it, and make applications available for free.

Form Details

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Where to Submit This Form

🏢

Submit to the hospital's financial counseling or billing department

501(c)(3) hospitals are required to have Financial Assistance Policies (FAPs) under IRS Section 501(r).

📬

Mail to the hospital's financial assistance department

Address listed on the hospital's financial assistance policy, which must be publicly available.

🌐

Apply through the hospital's website (if online applications are available)

Many hospitals now accept online financial assistance applications.

Filing Deadline

Hospitals must accept applications for at least 240 days after the first post-discharge billing statement. Apply as early as possible — before the bill goes to collections.

Required Attachments

📎 Completed financial assistance application (hospital-specific form)
📎 Proof of income (tax returns, pay stubs, unemployment documentation, Social Security statements)
📎 Proof of household size
📎 Bank statements (some hospitals require 3-6 months)
📎 Documentation of other medical bills or financial hardship

Processing Time

30-60 days for determination. Hospitals must not pursue extraordinary collection actions (lawsuits, liens, garnishments) while a pending application is being processed.

What Happens Next

The hospital will determine your eligibility for free or reduced-cost care based on their FAP. If approved, the hospital adjusts your bill. If denied, you can appeal. The hospital must provide a plain-language summary of the determination.

Tips for This Form

✓ All 501(c)(3) nonprofit hospitals are REQUIRED to have a Financial Assistance Policy — ask for it if not offered
✓ Apply even if you have insurance — high deductibles and out-of-pocket costs may still qualify you for assistance
✓ Hospitals cannot charge FAP-eligible patients more than the amounts generally billed to insured patients
✓ If the hospital has already sent your bill to collections, you may still be eligible — the 240-day window applies from the first billing statement

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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 501(c)(3) Nonprofit Hospitals 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.