Apply for the Financial Assistance Program
Visit the HSHS Financial Assistance Program website to fill out an application, or call our Customer Service department at 888-477-4221 for assistance. Return by deadline date. If help is needed, someone will be glad to assist you.
Please provide copies of the following items:
W2 withholding statements.
Most recent federal/state income tax forms.
Paycheck/Unemployment check stubs (past 3 months) or written statement of earnings from your employer (past 3 months).
Forms approving or denying Unemployment, Workers Compensation or Assistance from the Department of Public Aid.
Statement of annual benefits from Social Security.
Checking/savings account statements (past 3 months).
Other: letter explaining your situation.
Additional eligibility criteria may be available to you. For additional information, please contact the Illinois Single Billing Office at 1-877-636-2261.
Your Patient Account Representative can help you complete the form.