Instructions for completing this form

Please fill this form out completely and return all required documentation to the Intermountain facility where you had or plan to receive care for processing. Patients may not receive financial assistance if they do not complete the application process.

After completing the application form, please submit the following documentation:

1. Copies of your current federal tax return with all schedules, including W-2s

2. Household income verification (e.g. paycheck stubs) for the last two pay periods

Patients may not receive financial assistance if they potentially could qualify for programs, such as Medicaid, but choose not to apply.

If you don't have PIN number or need help to complete this form please call our Financial Assistance Department at 1-800-442-1128. Please check our website for additional information including Frequently Asked Questions, Plain Language Summary, and our Financial Assistance Policy.