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Step Two: Fill out your application

Ways to fill out your application form

Once you have confirmed you are eligible and have downloaded a copy of the application or received it in the mail from your hospital, it’s time to fill it out!

There are a few easy ways to do it:

1. Print it out and fill it out by hand.

This is by far the easiest option and is totally ok!  Just make sure your handwriting is readable and use black or blue ink.

2. Use a PDF editing tool on your computer.

If you don’t have a tool on your computer, there are free online tools like Sejda.com that can be used. Upload the document into the tool, then click where you want to type.  Make sure to add your signature where it is required on the form!

Information to share on your application form

Start by reading the instructions and the application carefully.  

The hospital is probably going to ask questions about:

  • What is the patient’s name and date of birth?
  • Who is responsible for paying the bill and their contact information?  This is sometimes called the guarantor.  A child’s bill, for example, would be paid by their parent.
  • Who are the members of the household?
  • How much money does each person in the household make and where do they work?
  • What are the monthly expenses of the household?
  • How much money does the family have saved in bank accounts or other investments?
  • Does anyone in the family receive any public assistance?

Fill in every question on the application that you possibly can.  If the answer is $0 or you don’t know, it’s ok to write that, but try to give them as much information as you can.  This is the best way to make your case that you do qualify for charity care. 

Make sure you sign the application where it asks for it!  Some hospitals also require a spouse or witness to sign.  Try to give them every signature requested so that you don’t have to fix it later and so they don’t have a reason to deny your application.

Attach the required documents to your application

In addition to the application, the hospital is definitely going to ask you for proof that what you say in your application is true.  Almost every hospital will require that you show them copies of: 

  • Your most recent three months of paystubs
  • Last year’s tax returns

Some hospitals will also ask for a lot of other documents. These might include:

  • Proof that you live in the state or county the hospital serves, like a utility bill with your name and address on it
  • Proof of health insurance, if you have it
  • Copies of bank account statements
  • Copies of unemployment benefit letters
  • Proof you have applied for Medicaid or other public health insurance programs

Carefully gather all of the requested documents.  It’s better to give them more documents than to give them less. Hospitals may deny your application if you don’t submit everything they require.

Frequently asked questions

Hospitals want proof that the financial information you have told them is true.  By showing them your pay stubs, tax forms, and other bank statements, you are showing them that you really are eligible for financial assistance.  They probably won’t approve your application if you don’t provide this info, so go ahead and provide it!



You should only include people on your application with whom you file taxes.  If your parents claim you as a dependent, you need to include them on the application.  But if you just live with someone and split the rent, then they should not be counted as part of your household.

If you are receiving unemployment or Social Security benefits, include that information in your application and send a copy of the benefits letter.  

If you are unemployed and don’t receive any benefits, include a letter or some notes that explains how you are supporting yourself financially without an income.  If someone is giving you money to pay for your expenses, be clear on how much money they are giving and what it is being used for. If you have applied for unemployment and been denied, it can be helpful to send that letter, too.

If you are making a lot less money now than you were before, make sure to include a letter that explains how much you make now and when it changed.  You will still need to submit those tax returns or pay stubs but you can show the hospital that you can’t afford to pay your bills with your current income. Make sure your application shows your current, not past, income.

Most hospitals post the financial assistance applications and policies online in several languages.  It’s always good to check if you can find an application in the language you need.  If not, call the hospital and ask if there is someone who can provide translation services.

You Don’t Have To Do This Alone! 

Dollar For can check if you are eligible,  send you tips on applying, or even submit an application to the hospital on your behalf.

Are you already in the process of applying for financial assistance?  Need help with a tricky situation?  Use our contact form to ask questions or get help with your case.

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