Geisinger is committed to providing healthcare to those in need, regardless of their ability to pay, so we offer a generous Financial Assistance Program.
To find out if you are eligible for Geisinger's Financial Assistance Program, print the financial statement application (located to the right) and complete all fields on the form. Use "N/A" if the information does not apply.
Applications with missing or incomplete information will be returned to you for the information to be provided, resulting in a delay in processing or possible denial. Upon completion of the form, please review for accuracy and mail with all applicable information outlined below to:
Geisinger Uncompensated Care Services 49-38
100 N. Academy Avenue
Danville, PA 17822-0002
All of the following documents are required, in addition to the completed financial statement, for your application to be processed:
- Most recent federal tax return, including all schedules, is attached and signed by all tax payers on form
- If you filed your taxes electronically, please sign the bottom of the form
- If you are not required to file taxes, you have indicated so on the financial statement
- Copies of the last three (3) months checking and/or savings accounts statements (must include all pages of the statement-summary pages will not be accepted)
- If no savings or checking accounts, you have indicated so on the financial statement
- Proof of income from all sources for all members of the household
- Employed: Copies of the four (4) most recent consecutive pay stubs, or letter from employer on letterhead outlining same information
- Unemployed: If no income exists, a notarized letter stating there is no income from any source
- Unemployment Compensation: Copy of eligibility determination letter, last four (4) pay stubs or copies of bank statement showing deposits
- Social Security/Disability: Copy of current year's benefit determination letter
- Pension: Copy of pension check, letter or bank statement showing deposits
- Alimony/Child Support: Copy of agreement, letter, check or bank statement showing deposits
- Most recent investment account statements: 401K/403B, IRA, Tax Deferred Annuity, CD, etc.
- Copy of medical assistance denial letter if you are enrolled in Medicare or do not have health insurance (denial must not be older than one year and must include all pages)
- Copy of denial or exemption letter from the Marketplace
- If married and currently separated, proof of separation
If you have questions or need help completing the form, call our Patient Service Call Center at 1-800-640-4206.