CHWC has two programs that offer financial aid to pay for hospital services. The first program is part of the Hospital Care Assurance Program (HCAP) through the State of Ohio, which mandates that hospitals offer free care to any patient who is an Ohio resident and whose annual income is at or below the federal poverty level. This program excludes Home Health, Hospice, and Long-Term Care. You may print and complete the Financial Assistance Application, and bring or mail it to CHWC with proof of your income for the 3 months or 12 months prior to your service. Your Patient Representative will use this information to verify your HCAP eligibility based on Federal poverty levels at the time of your service.

Financial Assistance Application

NOTE:  This application is a PDF file and is only capable of being viewed or printed with Adobe Reader.
If you do not have Adobe Reader you can download it for free by clicking the image below:
 

If you do not qualify for HCAP, we will process the Application under the CHWC Charitable Discount Program. Based on the information you provide on the Application, you may be eligible for a 30, 70 or 100% discount on your outstanding hospital balance. Please return the Application to...

CHWC Patient Accounts

433 W High Street

Bryan, OH 43506

If you have any questions on either of these programs, please contact your Patient Representative at 419-630-2149, Monday through Friday 7:00 a.m. to 4:30 p.m.

Thank You.