This form no long works. You’ll need to use our new form system to get help, including using our eligibility screening tool again.
Don’t worry! Our new system is much easier to use than the old system.
Want more info?
- Most hospitals offer discounts or bill forgiveness based on income. Learn more about charity care.
- Dollar For helps you apply for financial assistance from your hospital. We don’t pay your bills — we get the hospital to forgive them. Learn more about Dollar For’s services.