Financial assistance for UT, ID and NV

Couple looking at the finances online

Apply online

If you need help paying for medical care at an Intermountain Health location, you should apply for financial assistance. You can apply online in English and Spanish

Apply in EnglishApply in Spanish
Happy couple holding hands on a sofa at home

Mail in your application

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.

Download English ApplicationDownload Spanish Application
Woman in a blue headband sitting and talking to a doctor who is showing her something on a tablet

Do you need help paying your bill? Our financial counselors can see if you qualify for financial assistance or discounts, help you make a payment plan or discuss your other options

(866) 415-6556

Our financial assistance policy

When those who live in our communities need care, financial concerns should not prevent them from receiving treatment. Intermountain Health is committed to providing medically necessary care by offering financial assistance to individuals that qualify.

Intermountain Health offers financial assistance for patients who receive medical care provided in Intermountain clinics and hospitals. The program is for most medical care that a medical provider decides is needed. Intermountain’s Financial Assistance Program only applies to bills with Intermountain Health hospital, clinics, and some healthcare providers employed by Intermountain. Those in need of emergency care will never be denied treatment or care if they do not have insurance or are unable to pay.

  • Financial Assistance is determined on income and household size.
  • People eligible for financial assistance will not be charged more for emergency or other medically necessary care than the amounts generally billed to insured people.

Amounts Generally Billed (AGB) – The amounts generally billed for emergency or other medically necessary care to individuals who have insurance covering such care. Information regarding AGB percentages and calculations may be obtained in writing and free of charge by sending a request to financial.assistance@r1rcm.com or by writing to Financial Assistance, P.O. Box 30193 Salt Lake City, UY, 4130. AGB is calculated using the “Look Back method” in accordance with 501R federal regulations..

Intermountain Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. For more information, call 866-415-6556 (TTY:888-735-5906).

How do I apply?

You can apply online or by mail. Online applications and mail-in applications are linked above. If you receive (or plan to receive) medical care in an Intermountain hospital and have questions about financial assistance, please call 800-748-9175. If you receive (or plan to receive) medical care in an Intermountain clinic and have questions about financial assistance, call 866-415-6556. If you are interested in payment options, please call 866-665-2636. To apply for financial assistance in person, visit your local hospital or clinic where you receive services.

The documents below are available in eight languages. They will help you understand the process, file an application and learn about our financial assistance policy.

Apply for financial assistance

The information below will help you understand the process, file an application and learn about our financial assistance policy.

Please fill out the financial assistance form, provide required supplemental information and mail your completed application to:

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

After you submit your completed application, our financial counselors will review your application and contact you if they require additional information or to discuss your options.

Read our full policy about financial assistance.

Por favor complete el formulario de ayuda financiera, proporcione la información adicional necesaria y envié por correo su solicitud a:

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

Después de completar y enviar su formulario,nuestros asesores financieros revisarán su solicitud y se comunicarán con usted en caso de requerir información adicional o si fuere necesario discutir posibilidades o alternativas.

Lea en su totalidad nuestra política sobre ayuda financiera.

الرجاء ملئ استمارة المساعدة المالية، وتقديم المعلومات التكميلية المطلوبة وإرسال طلبك المكتمل إلى꞉

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

بعد تقديم طلبك المكتمل,، سيقوم مستشارونا الماليون بمراجعة طلبك والاتصال بك إذا كانوا بحاجة إلى معلومات إضافية أو لمناقشة خياراتك.

إقرأ بوليصتنا الكاملة حول المساعدة المالية.

请填写财务援助表,提供必要的补充资料,并将您填妥的申请邮寄至:

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

在您提交已完成的申请后, 我们的财务顾问将审查您的申请,如果他们需要额外的信息或需要讨论您的选择,他们将与您联系.

阅读了解有关我们财务援助的完整政策.

Veuillez remplir le formulaire d’assistance financière, fournir les renseignements supplémentaires requis et envoyez votre demande dûment remplie à:

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

Une fois que vous aurez remis votre demande dûment remplie, nos conseillers financiers vont examiner votre demande et ils vous contacteront si un complément d’information est nécessaire ou pour revoir vos options.

Lisez toute notre politique sur l’assistance financière.

재정 보조 신청서를 작성하신 후 부수적으로 요구되는 정보를 첨부하여 작성한 신청서를 다음의 주소로 보내 주시기 바랍니다

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

작성된 신청서를 제출하시면 재정, 상담사가 귀하의 신청서를 검토한 후 추가 정보가 필요하거나 선택사항에 대해 논의 필요 시 귀하에게 연락이 갈 것입니다.

재정 보조에 관한 저희의 정책을 자세히 읽어 보시기 바랍니다.

Пожалуйста, заполните форму заявления о предоставлении финансовой помощи, приложите к ней требуемые дополнительные сведения и отошлите их по почте по адресу:

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

После получения заполненного вами заявления, наши финансовые консультанты рассмотрят его и свяжутся с вами, если им потребуется дополнительная информация или они захотят предложить вам какие-либо варианты.

Также ознакомьтесь с нашими правилами о предоставлении финансовой помощи. 

Vui lòng điền vào mẫu đơn xin hỗ trợ tài chính, cung cấp các thông tin bổ sung được yêu cầu và gửi đơn đã hoàn tất đến:

Financial Assistance
PO BOX 27327
Salt Lake City, Utah 84127

Sau khi nộp đơn đã hoàn tất, các cố vấn tài chính của chúng tôi sẽ xem xét đơn của quí vị và liên hệ với quí vị nếu họ cần thêm thông tin hoặc để thảo luận về các lựa chọn dành cho quí vị.

Đọc toàn bộ chính sách về hỗ trợ tài chính của chúng tôi.