To apply for financial assistance, complete the Financial Assistance Application. Here is the secure online version of the financial assistance application in English and Spanish:

You may also print the application form, fill it out, and give the form, along with the appropriate documentation, to an Eligibility Counselor at an Intermountain facility.

  • To apply for Financial Assistance in person:
    1. Visit your local hospital or clinic where you receive services; or,
    2. Visit our Financial Assistance Office located at:
      Intermountain Healthcare
      4646 Lake Park Boulevard
      Salt Lake City, UT 84130

If you prefer, you can mail a completed financial assistance form to the facility where services were, or will be, provided.

Intermountain Healthcare Clinics

If you received (or plan to receive) medical care in an Intermountain clinic, and need to make arrangements for financial assistance to help pay for necessary medical care, please contact us at 1-800-442-1128.

How to Qualify

Some services offer a discount for the uninsured and financial assistance is available for qualifying patients. Provision can also be made for some patients who experience catastrophic healthcare events.

After patients provide information about household income, household size, expenses, and other personal circumstances, a cost of care compatible with the patient's ability to pay is determined.

Intermountain hospitals use a sliding scale that considers an individual's family income and family size, total amount of medical bills, and available liquid assets. Individuals whose family income falls below 150% of the Federal Poverty Guidelines may qualify for full assistance, minus a small co-pay per episode of care. The sliding scale extends to 500% of Federal Poverty Guidelines. The estimated ability to pay model attempts to determine what portion, if any, of an individual's income may be available to go towards paying for medical debt. As the sliding scale increases, more of an individual's income is potentially available to pay for medical services.

In addition, individuals with catastrophic medical bills may qualify for assistance. Intermountain hospitals currently define catastrophic assistance as situations where all medical bills (not only Intermountain medical bills) exceed 35% of a family's income.

Intermountain will also review an individual's specific situation to determine if additional assistance should be provided. Factors that meet the definition of extenuating circumstance include recent unemployment, certain life events (divorce, separation, death of a family member, etc.). Extenuating circumstances often provide a basis for providing additional financial assistance or for waiving a portion or all of the required financial assistance co-payment.

Financial assistance is available only to residents of Utah and certain parts of Idaho. Residence is defined as living in these areas for three or more months. Extenuating circumstances can be considered.