Qualifications for Charity Care

Do I qualify for Charity Care or Partial Charity Care?

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 Forms, please click on the PDF files below. Please download, print and complete the form. Attach copies of the following documentation as applicable:
  • Current Tax Returns
  • Last two bank statements including all checking, savings and investment/brokerage accounts
  • Last two pay stubs (if married, copy of your spouses are also required)
  • Award Letter (government support, student loans, etc.)
  • Copies of disability checks Copies of General Relief compensation Copies of unemployment compensation
Then, mail the form, letter, and supporting documents to: Pomona Valley Hospital Medical Center Attn:
Business Office 1798 N. Garey Ave Pomona, CA 91767. For questions regarding this form, please call: 909.865.9100.
 
To review the Financial Application Form, please click on the PDF below.

Financial Assistance Policy

Financial Assistance English Form

Financial Assistance Spanish Form

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