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Financial Assistance Application


Stanford Hospital & Clinics have a variety of options available for uninsured patients. For “No Interest Payment Plans” and “Uninsured Discounts” it is NOT necessary to fill out this application. No Interest Payment Plans generally require balances to be paid within 6 months of service. For other Medical Financial Assistance Options, please fill out all sections on the application below.

Financial Assistance Options Include (Application Required):

  • Financial Need Discounts- Discount at a rate comparable to our government payers. Some services may be excluded.
  • Full Financial Assistance- 100% of patient portion due. Some services may be excluded.
  • Extended No Interest Payment Plans- Available to patients who qualify for financial need discounts.

Financial Assistance Application Instructions:

A completed financial assistance application and proof of income must be submitted in order for us to consider a financial need discount and/or full financial assistance. Once we receive your completed application, we may assess whether or not you qualify for state or county programs. If this assessment determines you do not qualify for these programs, we will evaluate your financial assistance application to determine if you qualify for a financial need discount or full financial assistance. Those who qualify may receive assistance with their hospital bills for services provided at Stanford and physician bills for physicians employed by Stanford. Financial need discounting and full financial assistance is not available for all services. Consideration for future services will be based on medical necessity and catastrophic costs.

In considering financial assistance, our first priority is to assist those who have had emergency services. Next is to assist those who have had, or will have, medically necessary non-emergency services falling within either of the following two categories:

Category 1: Stanford Hospital & Clinics is the closest hospital to the patient’s home or place of work; OR

Category 2: Stanford Hospital & Clinics is not the closest hospital to the patient’s home or place of work but one or more of the following factors apply:

  • The patient has a unique or unusual condition which requires treatment at Stanford Health Care as determined by the Chief Quality and Medical Information Officer of SHC.
  • The patient’s care would further the institutions teaching mission as determined by the Chief Quality and Chief Medical Officer of SHC.

Important Information Required With Application

Proof of Income (POI): Kindly provide the following information, or an explanation as to why this information is not available. Missing documentation may delay the processing of your application and could result in a denial for assistance.


Type of Income Required docs
Employment Income • Copy of Individual tax return (Form 1040) for current tax year
• Copy of two most recent paystubs
Self-Employment • Copy of Individual tax return (Form 1040) for current tax year

Social Security/Retirement • Copy of Individual tax return (Form 1040) for current tax year
• Copy of Award Letter from Social Security Administration staling monthly
• Copy of monthly payment notification from Social Security Administration
Disability • Copy of Individual tax return (Form 1040) for current tax year
• Copy of Award Letter from disability stating monthly disability payment
• Copy of monthly payment notification from disability
Unemployment • Copy of Individual tax return (Form 1040) for current tax year
• Copy of Award Letter from unemployment stating weekly or monthly benefit amount
• Copy of monthly payment notification from unemployment
Spousal/Child Support • Copy of Individual tax return (Form 1040) for current tax year
• Copy of letter stating monthly award amount
Rental Property • Copy of Individual tax return (Form 1040) for current tax year
Investment Income • Copy of Individual tax return (Form 1040) for current tax year
Proof of Dependents • Copy of Individual tax return (Form 1040) for current tax year

*Every reasonable effort will be made to process your application promptly. Once application has been reviewed you will receive a letter confirming the outcome.

To help protect your personal information, please click the text "I'm not a robot" displayed below to proceed with the application.




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