Apply for Financial Assistance

 
  • ​Applicants can call Patient Financial Services at 715-717-4141 to make an appointment or for more information.

  • Patient Financial Services staff will assist the applicant in completing the Financial Assistance Application form.  The application can be found by visiting the HSHS Financial Assistance Program webpage and clicking on the Western Wisconsin Financial Assistance Application box.

  • The applicant will be required to furnish proof of income and information on assets and on possible future income. A tax return, bank statements and payroll stubs for the past 90 days must also be submitted for proof of income.

  • The Financial Assistance Committee will review the application and supporting documents and determine if the applicant meets the guidelines.

Eligibility 

 


Any patient or responsible party (i.e. head of household, spouse, parent, grandparent, etc.) who feels they may be in need of financial assistance can apply. The Hospital's Financial Assistance Guidelines will determine level of need and who qualifies.

To view current guidelines, please visit our HSHS Financial Assistance Program web page and select the Financial Assistance Brochure for Western Wisconsin. 

Qualification 

 

Applicants will be notified in writing if they are eligible and what percentage of their account will be credited. Patient Financial Services will subtract the approved financial assistance amount from the patient's bill and confirm payment arrangement on any remaining balance. A notation will be placed in the patient's file regarding what portion of their bill was forgiven through the Financial Assistance program.

If you do not qualify for Financial Assistance, you will be sent a letter explaining why you are not eligible. Ineligible applicants must make arrangements to pay their account by calling Patient Financial Services at 715-717-4141 within 14 days.

Applicants are eligible to reapply at any time for financial assistance if their financial situation changes.

Affordable Care Act (ACA) Price Transparency – Click HERE to learn more about the potential cost of your care.