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.