Financial Assistance Resources for Hospitals

WSHA continues to work with our member hospitals and health systems to make it easier for patients to apply for and get charity care. We created a standardized charity care application form that is available in multiple languages. We are pleased to say that these forms have been adopted by more than 90 percent of our member hospitals. 

WSHA Standard Documents

WSHA has developed a standard financial assistance application form and standard plan for communicating about financial assistance. The WSHA Board of Trustees unanimously voted to urge every hospital in Washington State that is subject to the state’s charity care law to adopt the standard application form and communication plan. Adopting the application and communication plan are the right thing to do for our patients, our communities, and our hospitals.

• Download guidance on adoption of standard application form and Instruction sheet—SHB 1616 Compliant (PDF)
• Download Tier 1 standard financial assistance/charity care application and Instruction sheet (Word Document)
• Download Tier 2 standard financial assistance/charity care application and Instruction sheet (Word Document)

WSHA has translated the WSHA standard application to the following languages: 

• • In Chinese (Simplified)
    • Tier 1 (Word Document)
    • Tier 2 (Word Document)
  • In Chinese (Traditional)
    • Tier 1 (Word Document)
    • Tier 2 (Word Document)
  • In Khmer
    • Tier 1 (Word Document / PDF)
    • Tier 2 (Word Document / PDF)
  • In Korean
    • Tier 1 (Word Document / PDF)
    • Tier 2 (Word Document / PDF)
  • In Laotian
    • Tier 1 (Word Document / PDF)
    • Tier 2 (Word Document / PDF)
  • In Russian
    • Tier 1 (Word Document / PDF)
    • Tier 2 (Word Document / PDF)
  • In Spanish
    • Tier 1 (Word Document / PDF)
    • Tier 2 (Word Document / PDF)
  • In Vietnamese
    • Tier 1 (Word Document / PDF)
    • Tier 2 (Word Document / PDF)
• Download standard communication plan for financial assistance/charity care (PDF)
• Download model plain language summary (Word Document)
• Sample policy language
• Sample Policy Language for Policy Updates Based on SHB 1616—updated 5/26/2022 (PDF)
• Guidance on staff training requirements
• List of Charity Care Hospital Tiers

We are here to help you as you ensure your charity care program is working. If you want a comprehensive review of your charity care program, consider purchasing a Charity Care Check Up from WSHA’s subsidiary, Washington Hospital Services. For more information about the Charity Care Check Ups, contact Ed Phippen at edp@wsha.org or by phone at 206-216-2556.