The Providence financial assistance application is the form uninsured or underinsured patients use to request reduced or fully forgiven bills at any Providence hospital or clinic. You can download it from providence.org/billing-support/help-paying-your-bill/app-support, pick up a paper copy at any Providence registration desk or financial counseling office, or call 855-229-6466 for help. There is no hard deadline to submit, and you can apply before, during, or after receiving care.
Who Qualifies
Eligibility depends on your household income compared to the Federal Poverty Level (FPL), and the thresholds vary by state. In Oregon, income at or below 200 percent of the FPL qualifies for a full write-off of your patient responsibility. Between 201 and 300 percent gets a 75 percent discount, 301 to 350 percent gets 50 percent, and 351 to 400 percent gets 25 percent.1Providence. Providence Financial Assistance (Charity Care) Policy – Oregon Montana sets the full write-off threshold higher, at 300 percent of the FPL, with an 80 percent discount for income between 301 and 400 percent.2Providence. Providence Financial Assistance (Charity Care) Policy – Montana
In dollar terms, the 2026 FPL for a family of four in the contiguous 48 states is $33,000, which puts the 200 percent cutoff at $66,000 and the 400 percent cutoff at $132,000.3HHS ASPE. 2026 Poverty Guidelines – Detailed Tables Alaska and Hawaii use higher FPL figures.
Providence also recognizes catastrophic medical expenses. In Montana, if your income is at or below 400 percent of the FPL and your total Providence medical costs over the past 12 months exceed 20 percent of household income, you qualify for a one-time full write-off of your balance as of the application date.2Providence. Providence Financial Assistance (Charity Care) Policy – Montana Check the policy document for the state where you received care, since the thresholds differ.
Assistance applies to emergency, urgent, and other medically necessary inpatient and outpatient services. Cosmetic, experimental, and investigative procedures are excluded.1Providence. Providence Financial Assistance (Charity Care) Policy – Oregon Not every provider who treats you inside a Providence facility is necessarily covered; some physicians bill independently. The policy lists which providers are included, so ask the financial counseling office about any specific bill you are unsure of.4Internal Revenue Service. Financial Assistance Policies (FAPs)
Documents to Gather
Assembling paperwork before you sit down with the form prevents most delays. Providence accepts several types of income proof depending on your situation.
If you are employed, bring last year’s tax return, W-2 forms, or recent pay stubs. A letter from your employer works if you do not receive formal pay stubs. If you are self-employed, Providence specifically asks for a 90-day profit and loss statement rather than a tax return alone.5Providence. Frequently Asked Questions – Billing Support
Other income sources need their own documentation: Social Security award letters, unemployment statements, disability benefits paperwork, child or spousal support records, and statements for income from stocks, bonds, IRAs, or rental property.6Providence. Charity Care/Financial Assistance Application Form Bank statements are not always required upfront but may be requested as supplemental documentation during review, so keep recent ones handy.5Providence. Frequently Asked Questions – Billing Support
Also list every person living in your household, including children and dependent adults. Household size determines which FPL bracket applies, so an accurate count matters. You will report monthly expenses such as rent or mortgage and utilities as well.
Filling Out the Form Without Stalling It
Providence uses slightly different application versions by state. Make sure you download the one for the state where you received care.7Providence. Financial Assistance Application Support
A few sections trip people up. Gross monthly income means income before taxes and deductions for every adult in the household. Reporting take-home pay instead of gross is the most common error, and it can either lower your assistance level or trigger a clarification request that delays the whole review.6Providence. Charity Care/Financial Assistance Application Form Complete every field about health insurance, even if you believe you are uninsured; mark the appropriate box rather than leaving it blank. Sign the attestation at the end. An unsigned application will not be processed.
Do not skip any section. Incomplete fields are the single most common reason applications stall. If a question does not apply, write “N/A.”
How to Submit
You have three ways to get the completed application and supporting documents to Providence.
- By mail, to the Providence Regional Business Office. The address printed on the Montana application is P.O. Box 31001-3422, Pasadena, CA 91110-3422. Verify the address on your state-specific form, since regions may route mail differently.6Providence. Charity Care/Financial Assistance Application Form
- In person, to the financial counseling department at any Providence facility. Ask for a receipt.
- Through MyChart. Scan and attach signed documents and income proof, then submit electronically. The portal generates a confirmation you can save.8Providence. Financial Assistance Application – Patient Agreement
What Happens After You Submit
Providence processes applications within 14 to 30 days of receiving a complete package with all required documentation. In Washington State the turnaround is 14 days; in most other states, expect closer to 30.5Providence. Frequently Asked Questions – Billing Support6Providence. Charity Care/Financial Assistance Application Form If you submitted without all required documents, the clock does not start until Providence has everything it needs.
A decision letter arrives by mail explaining whether you qualify, the percentage covered, and your appeal rights. MyChart users can also see updated balances and decision details in their account.
Providence warns that billing statements may keep arriving until your completed application and documentation are in hand, unless state law says otherwise.6Providence. Charity Care/Financial Assistance Application Form In Washington, state law prohibits a hospital from initiating collection efforts against any patient who has submitted a completed charity care application until a determination is made.9Washington State Legislature. RCW 70.170 – Health Data and Charity Care A billing statement during review does not mean collections have started.
Approval Without Filling Out the Form
Providence does not always require a completed application. The system uses Experian, a financial assessment tool, to estimate your household income and family size. If that analysis puts you within the eligibility thresholds, Providence can grant a write-off without any form from you.1Providence. Providence Financial Assistance (Charity Care) Policy – Oregon
This presumptive screening typically applies to patients who are uninsured, enrolled in a state medical assistance program like the Oregon Health Plan, or who owe more than $1,500 for a single hospital encounter after insurance adjustments. In Oregon, presumptive write-off levels range from 100 percent at or below 200 percent of the FPL down to 25 percent at 351 to 400 percent, and a separate pre-collections screening can grant a full write-off for estimated income at or below 300 percent.1Providence. Providence Financial Assistance (Charity Care) Policy – Oregon
If you received a bill and believe you should have been screened, call 855-229-6466 and ask whether presumptive eligibility was evaluated. If it was not, you can still submit a full application.10Providence. Contact Resources – Billing Support
If Your Application Is Denied
The determination letter explains the reason. Common ones are incomplete documentation, income above the eligibility thresholds, or failure to respond to requests for additional information.
Submit a written appeal by mail to the Providence Regional Business Office, P.O. Box 3299, Portland, OR 97208-3395.11Providence. Help Paying Your Bill Include a letter explaining why you disagree and any new documentation, such as updated pay stubs or a termination notice if your income dropped after the period your original proof covered. Keep copies of everything you send.
Even after a denial, ask the financial counseling office about a payment plan or a discount outside the formal assistance program. Providence would rather negotiate a payment arrangement than send the account to collections.
Federal and State Protections
Providence is a tax-exempt hospital system, so it must comply with Section 501(r) of the Internal Revenue Code. Every tax-exempt hospital must maintain a written financial assistance policy, make it and the application form freely available online and on paper, and notify the community it serves.4Internal Revenue Service. Financial Assistance Policies (FAPs)
Section 501(r)(6) also bars a tax-exempt hospital from taking “extraordinary collection actions” against you until it has made reasonable efforts to determine whether you qualify for financial assistance. Those actions include selling your debt, reporting to credit bureaus, placing liens, garnishing wages, and filing lawsuits.12Internal Revenue Service. Billing and Collections – Section 501(r)(6)
Some states go further. Washington’s RCW 70.170 requires hospitals to use a standardized charity care application, decide within 14 days of a complete submission, and refrain from any collection efforts while the determination is pending.9Washington State Legislature. RCW 70.170 – Health Data and Charity Care Washington law also requires hospitals to make a good-faith effort to screen every patient for charity care eligibility before pursuing aggressive collection actions.13Washington State Legislature. RCW 70.170.060 – Charity Care – Prohibited and Required Hospital Practices and Policies Oregon has its own hospital financial assistance requirements setting minimum assistance levels for state residents. Where a state statute gives more protection than the federal floor, the hospital must follow the state rule. When in doubt, ask the financial counseling office which rules apply to your account.