How to Fill Out and Submit the BJC Financial Assistance Application

The BJC financial assistance application is a short form that, if approved, can wipe out 80 to 100 percent of your bill for emergency and medically necessary care at a BJC HealthCare hospital. You can submit it before, during, or after treatment, but BJC must receive your completed application within 240 days of your first billing statement. Qualification depends on where you live, your household size, and your income compared to the Federal Poverty Level.¹

Check Whether You Qualify First

Three things decide eligibility: residency, income, and the type of care.

You must live in Missouri or Illinois. The one exception is patients treated at a National Health Service Corps site within the BJC system, who qualify regardless of residence.¹

Income is measured against the Federal Poverty Level for your household size. If your family income is at or below 200 percent of the poverty level, BJC covers 100 percent of the eligible balance. For a household of four in 2026, that ceiling is roughly $66,000.² Between 201 and 300 percent of the poverty level, you get an 80 percent discount and owe the remaining 20 percent.³ For that same family of four, 300 percent is about $99,000.

Two limits worth knowing. The discount schedule stops at 300 percent, not 400 percent, so incomes between 300 and 400 percent do not qualify even though some other hospital systems cover that band. And there is a flat cap: families earning over $100,000 per year are ineligible regardless of household size.¹

Only emergency and medically necessary services are covered. Elective procedures such as cosmetic surgery are excluded. If insurance or a government program has already paid part of your bill, the discount applies only to what you still owe, not to the paid portion.¹

One shortcut: if you were enrolled in Medicaid or deemed eligible for the Gateway to Better Health program within the past six months, you automatically qualify for BJC financial assistance on services Medicaid did not cover. Pregnancy-related Medicaid enrollment does not trigger the automatic qualification, but you can still apply through the standard process.¹

Gather Your Documents Before You Start

Proof of income is the piece that most often holds an application up. BJC accepts any one of the following:

Your most recent federal tax return (any complete return; no specific IRS form is required).
Your most recent W-2 and 1099 forms, if you have not filed yet.
Your two most recent pay stubs.

The form also asks for monthly dollar amounts across specific income categories, including Social Security, disability benefits, veterans’ pensions, unemployment compensation, workers’ compensation, retirement income, and Temporary Assistance for Needy Families. Pull the relevant benefit statements or award letters so you can enter accurate figures.⁴

Have your employer’s name, address, and phone number ready, and the same for a spouse or partner if applicable.

Filling Out the Form

Download the application from BJC’s billing and financial assistance page at bjc.org, or pick up a paper copy at any BJC hospital registration desk.⁵ It runs a few pages and breaks into three parts.

Patient and Household Information

The first section asks for your name, date of birth, address, and contact information, plus the number of people in your household. This household figure pairs with your income on the poverty-level table, so count carefully. Include everyone who lives with you and shares financial resources: spouse or partner, dependent children, and other family members in the home.

Employment and Monthly Income

Next is your employment information and a line-by-line monthly income breakdown. About a dozen income categories are listed. Fill in every line that applies. If a category does not apply to you, write zero rather than leaving it blank; empty lines can trigger a request for more information and slow the review. Attach the proof-of-income document you chose.⁴

Signature

The last page needs your signature and the date. If someone else is financially responsible for the account, such as a spouse, parent, or guardian, they need to sign too. An unsigned application is treated as incomplete, and it is the most avoidable reason for a delay.

Where to Send It

You have four options for submitting:

Mail the form and supporting documents to the Patient Accounts address printed on the application.
Email the package to patacct@bjc.org.
Fax it to 314-747-6977.
Drop it off in person at any BJC hospital registration desk.

For help with the application itself, call BJC’s financial assistance line at 314-747-8845 or toll-free at 844-747-8845.⁵

The deadline is firm. Your completed application must be received within 240 days of the date on your first billing statement for the services in question.¹ You may apply before you receive care, while you are still in the hospital, or after the bill arrives, but the 240-day window closes on the same date either way.

After You Submit

BJC’s review team compares your reported income and household size against the discount schedule and mails a determination letter to your home. The letter states either the percentage of your bill that has been forgiven or the adjusted balance you still owe. Approved discounts are applied directly to your account.

An approval is good for 12 months from the date of the decision, so additional eligible services during that period fall under the same terms without a new application.¹

If you are denied, the letter will explain why. BJC will consider exceptions on a case-by-case basis, so if your situation is unusual, such as a sudden job loss or a catastrophic medical event, you can request an individual review.¹

Collection Protections While Your Application Is Pending

BJC hospitals are 501(c)(3) nonprofits, and federal law restricts what the hospital can do to collect from you during the notification and application periods. Under Section 501(r)(6) of the Internal Revenue Code, the hospital must give you at least 120 days from your first post-discharge billing statement before it can take any extraordinary collection action, and you have 240 days from that same statement to submit a complete financial assistance application.⁶

Extraordinary collection actions include reporting the debt to credit bureaus, selling the account to a third-party debt buyer, filing a lawsuit, garnishing wages, placing a lien on your property, seizing a bank account, and refusing medically necessary care because of an unpaid balance from earlier treatment. None of these can happen during the protected windows, and the hospital remains responsible even if a collection agency it hired takes one of these steps.⁶ If you send in an incomplete application within the 240 days, BJC has to tell you what is missing and give you a reasonable chance to fix it before restarting collections.

Extra Discount for Uninsured Illinois Patients

Uninsured Illinois residents who receive care at Alton Memorial Hospital, Memorial Hospital Belleville, or Memorial Hospital East may qualify for additional discounts beyond the standard BJC schedule under the Illinois Hospital Uninsured Patient Discount Act. You use the same application form; BJC determines whether the Illinois-specific discount applies based on your hospital location and insurance status.³

Common Reasons Applications Get Delayed

Most stalled applications share the same handful of problems: no signature, no proof of income, or blank income lines. Before you submit:

Attach one of the three accepted income documents. An application without documentation will not be processed.
Fill in every income line. Write zero where a category does not apply.
Sign and date the form, and have any financially responsible party sign as well.
Keep a copy of everything you send in case something is lost in transit.
Watch the 240-day clock. It runs from your first billing statement, not from the date of service.

1
BJC HealthCare. BJC Financial Assistance Policy
2
HHS ASPE. 2026 Poverty Guidelines – 48 Contiguous States
3
BJC HealthCare. BJC Financial Assistance Income and Discount Schedule
4
BJC HealthCare. BJC HealthCare Financial Assistance Application
5
BJC HealthCare. Billing and Financial Assistance
6
Internal Revenue Service. Billing and Collections – Section 501(r)(6)