Financial Assistance Program Application & Instructions
Dear Applicant:
Thank you for allowing us to be of assistance to you. Attached is an application for the Financial Assistance Program offered by Renown Health. The purpose of the Financial Assistance Program is to provide financial relief to guarantors who do not qualify for Federal, State, or County assistance, and have no reasonable means to meet their financial obligations for necessary medical services. The documents requested are used solely to determine eligibility for the Financial Assistance Program. If you have not applied directly for Federal or State assistance, we can help you with a simple screening to determine your potential eligibility. You may be required to submit proof of approval / denial for assistance through your State Welfare programs if your income meets the eligibility criteria. Please contact our Financial Assistance Specialist for help in determining your eligibility by calling 775-982-5747.
Financial Assistance Requirements:
� All items on the application must be completed in full.
� A co-payment may be determined based on prescreen and is required at the time you submit your application. Payment will be applied to any outstanding balances regardless of application approval.
� Proof of Income( attach copies): o Recent month of Pay Stubs and / or other Source of Income( social security, unemployment, child support, alimony, etc.). o Last month’ s Bank Statements( include linked accounts, all pages). o Last month’ s / quarter’ s statement from any Other Asset Accounts( i. e., Life insurance policies / Distributions, Stocks, Bonds, Certificate of Deposits, Investments, Cryptocurrency, legal settlement funds, etc.). o Prior Year Filed Tax Forms( 1040 forms and corresponding schedules).
After all supporting documentation has been submitted, you will be notified in writing of the final determination of your eligibility. Please update us if your address or phone numbers change. If you have any questions regarding the Financial Assistance Program or need help completing the application form, please contact a Financial Assistance Specialist at Renown Health by calling 775-982-5747.
Renown Health 10315 Professional Circle T-6 ATTN: Financial Assistance Program Reno NV 89521 P 775.982.5747 F 775.982.8036 FAP @ Renown. org
IMPORTANT: Please read and complete the form before signing. Accurate information is needed for proper processing.
Page 1 of 2 Form Number: 100-169 Revision Date: 1 / 2026