Office hours: Monday–Friday, 7 a.m.–4:30 p.m.
If you do not have health insurance or are underinsured, we invite you to apply for financial assistance. You may be eligible for a full write off under the State of Ohio’s Hospital Care Assurance Program (HCAP) or for discounted rates under our own financial assistance program. You can learn more by clicking the link below for a plain language summary.
Our application for financial assistance is used to determine eligibility for both programs. You can download and print the application below. Fill out the application completely and either bring it in person to CHWC or mail it to CHWC. You will need to include with the application proof of your income for at least the most recent three (3) months, or twelve (12) months prior to your services. You will also need to include proof of cash assets.
Our patient representatives will use the information from your completed application and proof of income to determine your eligibility for assistance (based on each program’s criteria at the time of service).
Completed applications can be delivered to CHWC in person, or mailed to:
CHWC Patient Accounts
433 W. High Street, Bryan, Ohio 43506
Here are our available forms and policies:
Financial Assistance Application Form