The Ascension financial assistance application is a paper or PDF form you submit with proof of income and assets to ask Ascension to discount or forgive a hospital bill. Download the form for the specific hospital where you were treated from healthcare.ascension.org/financial-assistance, or pick one up at that facility’s financial counseling office. The program covers emergency and medically necessary hospital services for patients who are uninsured, underinsured, or facing costs that are large compared to their income.
Whether You’ll Qualify
Ascension looks at your household size and total gross income against the Federal Poverty Level guidelines published each year by the U.S. Department of Health and Human Services. Two tiers do most of the work:
- Income at or below 250% of the FPL may qualify for a 100% charity write-off, meaning your entire patient responsibility is forgiven.
- Income between 250% and 400% of the FPL qualifies for a sliding-scale discount. One Ascension region, for example, discounts 95% at 275% FPL and steps down to 75% or 65% at 400%, depending on the facility.1Ascension. Ascension Wisconsin Financial Assistance Policy
For 2026, a single person hits 250% FPL at $39,900 in annual gross income and 400% FPL at $63,840. A family of four reaches those thresholds at $82,500 and $132,000. The thresholds are higher in Alaska and Hawaii.2HHS ASPE. 2026 Poverty Guidelines
Income isn’t the only test. Ascension also counts your assets: bank accounts, investments, stocks, trust funds, and money market accounts. If your total assets exceed 250% of the FPL income figure for your household size, you may be denied even when your income is within range.3Ascension. Summary of Financial Assistance Policy
Catastrophic Costs Above 400% FPL
Some Ascension facilities offer a catastrophic discount even when your income is above 400% FPL. It caps out-of-pocket costs when medically necessary charges over a 12-month period exceed 25% of your family’s gross income.4Ascension. Financial Assistance at Ascension Illinois Ask about it if the standard tiers don’t fit but a single episode of care hit you hard.
Presumptive Eligibility
Ascension may approve some patients automatically without an application, using internal screening or third-party data. If that happens you’ll be notified. Most patients should still plan on completing the full application.
What the Program Covers
Financial assistance applies to hospital charges for emergency and medically necessary services at participating Ascension facilities.3Ascension. Summary of Financial Assistance Policy Elective procedures that aren’t medically necessary are excluded.
Important boundary: not every bill from your hospital visit is a hospital bill. Doctors, anesthesiologists, radiologists, and other providers who treated you at the facility often bill separately, and their charges may not fall under Ascension’s policy. Each facility publishes a list of covered and non-covered providers. Check the list for your hospital on the financial assistance page, or call the patient representative before assuming a particular bill is eligible.4Ascension. Financial Assistance at Ascension Illinois
Documents to Gather Before You Start
An incomplete application won’t be processed. Collect everything first. Ascension asks for proof in three categories: income, assets, and (optionally) outstanding medical debt.5Ascension. Financial Assistance Application
Income
- Three most recent paystubs from each employed household member
- Most recent federal tax return, with all schedules if self-employed
- Social Security or pension award letter, if applicable
- Unemployment benefits receipt, if applicable
- Parent or guardian’s tax return if the patient is a dependent under 25
- Medicaid or state assistance approval or denial letter
Assets
- Bank statements (checking and savings) from the last three months
- Investment statements for stocks, bonds, mutual funds, or money market accounts
- Trust fund documentation, if applicable
Outstanding Medical Bills
If you want Ascension to weigh your overall medical debt burden, attach current invoices or account balance statements from other providers. This is optional but can help your case.5Ascension. Financial Assistance Application
If You Have Little or No Income
Applicants who report zero or very low income and get help with living expenses from family or friends must submit a Letter of Support. The person helping you writes a short statement with their name, relationship to you, and address, certifies that you receive little to no income, and confirms that they help with your living expenses. A copy of that person’s photo ID goes with the letter. The letter does not make them responsible for your medical bills.6Ascension. Financial Assistance Application If nobody helps you financially, skip the letter and simply sign the application certifying that your income information is accurate.
Filling Out the Form
The form is straightforward but unforgiving about blanks. Each section asks for something specific:
- Patient information: your full legal name, date of birth, address, phone, and the account number and date of service from your bill. Copy the account number straight off the billing statement.
- Household members: everyone living with you, their relationship to you, and whether they earn income. This sets your household size for the FPL calculation.
- Income details: every source of money coming in, including wages, self-employment, Social Security, disability, pension, child support, and unemployment. If income is irregular, use a monthly estimate and note that it varies.
- Assets: bank balances, investments, and other liquid resources for all household members.
- Monthly expenses: rent or mortgage, utilities, food, transportation, insurance premiums, and other recurring bills.
- Insurance status: whether you’re covered, insurer name and policy number, or confirmation that you’re uninsured. Note any Medicaid or other government program applications and the result.
- Signature and certification: sign and date. An unsigned application will be returned.
Make copies of the completed application and every attachment before sending anything out. Put your name and account number on every page. If pages separate during processing, unlabeled documents can be lost or mismatched to another patient’s file.
Submitting the Application
Three routes get the finished package to Ascension:
- Mail: send it to the address printed on your facility’s form. Addresses vary by market, so use the one on the form you downloaded. Registered or certified mail gives you a delivery receipt.7Ascension Wisconsin Hospital. Financial Assistance
- In person: drop the envelope at the financial counseling office or main registration desk at the hospital where you received care. Staff will forward it.
- Phone help: for questions while completing the form, call Ascension’s billing support line at 833-470-9053, Monday through Friday, 7:00 a.m. to 5:00 p.m. Central Time.8Ascension. Billing FAQs
How Long You Have to Apply
Ascension’s forms don’t state a hard deadline from your date of service, but federal rules set the window. Under IRS Section 501(r)(6), a tax-exempt hospital cannot start extraordinary collection actions such as lawsuits, wage garnishment, selling debt to a collection agency, or reporting to credit bureaus until at least 120 days after the first post-discharge billing statement. The hospital must also accept and process any complete application submitted during a 240-day application period.9Internal Revenue Service. Billing and Collections – Section 501(r)(6) Submit as soon as you reasonably can, but know you have room if it takes weeks to gather documents.
After You Submit
Once the billing office confirms your application is complete, expect a determination letter within 45 business days.10Ascension. Financial Assistance Application Cover Letter If a document is missing, the clock doesn’t start until the office has everything.
While the review is pending, Ascension must suspend extraordinary collection activity on the account under review.9Internal Revenue Service. Billing and Collections – Section 501(r)(6) Routine billing statements may still arrive, but no one should be calling from a collection agency or filing suit.
The letter will say one of three things:
- Full write-off, with a revised statement showing a zero balance.
- Partial discount, with the new amount you owe.
- Denial, with a brief explanation.
How Long an Approval Lasts
An approval generally stays valid for six months. If you get more care during that window, tell the billing office you already have an approved application on file and you may not need to reapply. After six months, Ascension can’t rely on the old application and you’ll need to submit a new one for future services.11Ascension. Financial Assistance Application
If You’re Denied
You can appeal by sending additional information to Patient Financial Services within 14 calendar days of the denial notice. A committee reviews appeals monthly and may approve, deny, or table the request pending more documentation. The final decision comes in writing.12Ascension. Ascension Illinois Financial Assistance Policy
Fourteen days is tight. Read the denial explanation carefully, then respond directly to the gap it identifies. A job-loss letter, updated bank statements, or proof of new medical expenses can all support an appeal if they speak to why the initial reviewer said no.
Paying What’s Left After a Partial Discount
A partial discount still leaves you owing the reduced balance. If you can’t pay in a lump sum, call the billing office at 833-470-9053 to set up a payment plan.8Ascension. Billing FAQs Getting a plan in place quickly keeps the account from aging toward collections after you’ve already done the work of applying.