Financial Counseling

Financial Assistance

Application for Seattle Children's Financial Assistance (Charity Care)


Financial Assistance eligibility is based on monthly family income, family size, residency and age. To begin the application process, make sure you have the names and birthdates of all children living in your home, as well as your monthly income and health insurance premium information. Then complete and submit this form. If you have questions, call Financial Counseling at 206-987-3333.

Application is available in Spanish, Somali, Vietnamese, Russian and English.

Financial Assistance Application Administration

APPLICATION STATUS
Application ID#:
Application Date:
Application Status:
PLEASE SELECT ONE OF THE FOLLOWING
I am the parent/guardian, applying for one or more of my dependent children
I am the patient applying for myself (18 years or older)
I am the patient applying for myself (18 years or older) and for my dependent children
CHILDREN RECEIVING CARE AT CHILDREN'S
First Name
MI
Last Name
Birth Date
Gender
MRN
NAME(S)
Parent/Gaurdian/Spouse
Self
OTHER CHILDREN OR TEENS
First Name
MI
Last Name
Birth Date
PREGNANT HOUSEHOLD MEMBER
HEALTH INSURANCE INFORMATION
Insurance Name :
Premium :
FAMILY INCOME
(Insurance premium, if any, is subracted from total income)
Monthly Gross Income:
Monthly Self-employment Income:
Monthly Unemployment Income:
Other Monthly Income:
Total Income:
SCREENING INFORMATION
If we need to contact you for additional information, do you need an interpreter?*
Please select valid option.
Please list preferred language: *
Please enter your preferred language.
Have you applied for Medicaid for the patient? *
Please select valid option.
You may be required to apply for Medicaid before being considered for financial assistance. We will contact you if needed.
Does the patient receive state public services such as TANF, Basic Food or WIC? *
Please select valid option.
Is the patient currently homeless? *
Please select valid option.
Is the patient's medical care need related to a car accident or work injury? *
Please select valid option.
PATIENT AND APPLICANT INFORMATION
Patient
First Name: *
Please enter first name.
MI:
Last Name: *
Please enter last name.
Birth Date: *
Please select birth date.
Person responsible for paying bill
Same as patient
First Name: *
Please enter first name.
MI:
Last Name: *
Please enter last name.
Relationship to Patient: *
Please enter a relationship.
Birth Date: *
Please select birth date.
Mailing address
Address 1: *
Please enter an address.
Address 2:
City: *
Please enter a city.
State: *
Please select a state.
Zip: *
Please enter a valid postal code.
Main contact number(s)
Phone Number: *
Please enter valid phone number.
Phone Number:
Please enter valid phone number.
Email Address
FAMILY INFORMATION
List all family members in your household, including yourself and patient. "Family" includes people related by birth, marriage or adoption who live together.
Income is required. Please enter 0 (zero) for children or family members with no income. Please list your MONTHLY income.
Name *
Birth Date *
Relationship to patient *
Seattle Children’s Medical Record Number
If 18 years or older: total gross monthly income *
Name *
Please enter name.
Birth Date *
Please select birth date.
Relationship to patient *
Please enter a relationship.
Seattle Children’s Medical Record Number
If 18 years or older: total gross monthly income *
Please enter a monthly income.
Name *
Please enter name.
Birth Date *
Please select birth date.
Relationship to patient *
Please enter a relationship.
Seattle Children’s Medical Record Number
If 18 years or older: total gross monthly income *
Please enter a monthly income.
Total ANNUAL income: $0
*Gross monthly income is income before taxes and deductions
All adult family members' income must be disclosed.
Sources of income include, for example:
Wages, unemployment, self-employment, worker's compensation, disability, SSI, child/spousal support, work study programs (students), pension, retirement account distributions.
We may ask you to provide proof of income such as pay stubs or last year's income tax return. We will contact you if we need those items.
If you have no income, please explain how you are paying for food and housing:
If you have no income, please explain how you are paying for food and housing.
MEDICAL INSURANCE AND EXPENSE INFORMATION
Do you have insurance ? *
Please select valid option.
TOTAL INCOME
Total household monthly income:
ADDITIONAL INFORMATION
Please provide any additional information about your financial situation you would like us to know (e.g. financial hardship, seasonal or temporary income, personal loss).
STAFF COMMENTS
Add your comments below:

AGREEMENT
I understand Seattle Children's Hospital may verify the information on this form and may use other sources to help determine if I am eligible for financial assistance or payment plans. I affirm that the above information is true and correct to the best of my knowledge. I understand if the information I give is false, I will be denied financial assistance, and I will be responsible for and expected to pay for services Seattle Children's provides.
Please check the box to acknowledge your consent and agreement
Please check the box to acknowledge and consent.
Please enter your name.