Financial Assistance Program

Do I qualify for Financial Assistance?

Pomona Valley Hospital Medical Center strives to meet the health care needs of all patients who seek inpatient, outpatient and emergency services. PVHMC is committed to providing access to financial assistance programs when patients are uninsured or underinsured and may need help in paying their hospital bill. These programs include government sponsored coverage programs, charity care and discount partial charity care as defined.
 
To view our Financial Assistance Policy and Financial Assistance Application, please click on the PDF files below. Please download, print and complete the application and attach copies of the following documentation as applicable:
 
To determine eligibility and to maximize the qualifying assistance/discount amount, the following documentation is required when applicable:
  • Completed & signed financial assistance application;
  • Current pay stubs from the last two pay periods or if self‐employed, current year‐to‐date profit & loss statement to determine current income;
  • Award letters for social security, SSI, Disability, Unemployment, General Relief, Alimony, etc.;
  • For full charity only, last calendar year’s filed tax return with all required schedules to determine income generating assets including monetary assets for a full charity discount only;
  • For full charity only, last two months’ bank, brokerage & investment statements for a full charity discount only;
  • For full charity only, copies of prior year’s 1099 for interest income, dividends, capital gains, etc.
Then, mail your application and supporting documents to: Pomona Valley Hospital Medical Center Attn:
Eligibility Services 1770 Orange Grove Ave, Suite 230, Pomona, CA 91767. For questions regarding this form, please call: 909-469-9441.

Financial Assistance Policy

Politica del Programa de Asistencia Financiera al Paciente

Financial Assistance English Application

Financial Assistance Spanish Application

Financial Assistance Policy Plain Language Summary

Resumen en Lenguaje Simple de la Politica de Asistencia Financiera

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