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 1-800-994-0368 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 1-800-994-0368.

Your Patient Account Representative can help you complete the form.

Eligibility is determined by family income and family size.


Income guidelines for eligibility are adjusted annually based on the Federal Poverty Guidelines established by the United States Department of Health and Human Services and published periodically in the Federal Register. These guidelines are subject to change without notice.

To view current guidelines, please visit the HSHS Financial Assistance Program web page and select the Financial Assistance brochure for the Illinois Single Billing Office. 

Learn More And Apply

If You Qualify

  • Applicant will be notified in writing that they are eligible and what amount of assistance has been allowed.

  • Adjustments will be made to bill and payment plan will be established on remaining balance, if one exists.

  • Applications will be held on file and will remain valid for six (6) months for future visits.

If You Do Not Qualify

  • Applicant will be sent a letter stating the reason for ineligibility along with an itemized statement.

  • Applicant must make financial arrangements to pay the enclosed statements with a patient account representative with ten (10) business days or the balance will be due within thirty (30) days.

  • Applicants are eligible to reapply for assistance if their financial situation changes by calling our Customer Service department at 1-800-994-0368 for reevaluation of eligibility.

If you have any questions or concerns about your billing statement or you require financial assistance, please contact our Customer Service department at 1-800-994-0368.

Patient Account Representatives

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