Financial Assistance Application

If you do not have insurance coverage, or are underinsured, you may be eligible for charity care or other hospital discount. Any individual whose family income is at or below 400% of the Federal Poverty Level may be eligible for discounted services under the hospital’s charity care policy. In addition, patients without insurance coverage may be eligible for government programs such as Medi-Cal, County Indigent and other government funded healthcare assistance programs. You are also welcome to obtain applications for coverage offered through the California Health Benefit Exchange: www.coveredca.com, or through the Riverside Department of Public Social Services at (800) 274-2050 or rivcodpss.org, or by contacting Health Consumer Alliance at healthconsumer.org.

1. Please indicate if you are applying for Charity Care or Discount Payment by checking the appropriate box below.
   • Charity Care – If approved, this can provide up to a full write-off of all patient balances included in the approved time period.
   • Discount Payment – If approved, this can provide a reduced payment of up to 70% of all patient balances included in the approved time period.
2. Please complete all areas on the attached application form. If any area does not apply to you, please write N/A (not applicable) in the space provided.
3. Attach an additional page if you need more space to answer a question.
4. You must provide proof of income when submitting this application. One of the following documents must be attached:
   1. Prior year’s Federal Income Tax Return (ex. form 1040) and should include all schedules and attachments, as submitted to the Internal Revenue Service (IRS).
      OR
   2. Six (6) months of most recent paycheck stubs or social security, disability, or unemployment benefit statements.
5. Letter explaining your current situation and why payment arrangements cannot be made. A letter from the person providing support if no income is received.
6. Your application cannot be processed until all required information is provided. It is important that you complete and submit the financial assistance application along with all required documentation as soon as possible.
7. You must sign and date the applications. If the patient/guarantor and spouse provide information, both must sign the application.
8. If you have questions, please contact a Patient Financial Services Representative at 760-837-8376.
9. Submit your completed application.
   1. Download and complete the Financial Assistance Application form and mail or it fax to:

      Eisenhower Medical Center
      Attn: Patient Financial Services Department – Financial Assistance
      39000 Bob Hope Drive
      Rancho Mirage, CA 92270
      Fax 760-773-4317

      
      OR
   2. Complete the online form below: