Additional Documentation Upload "*" indicates required fields InstagramThis field is for validation purposes and should be left unchanged.List of CommonSpirit Health location(s) where patient was treated. *Patient Name* First Last Patient Date of Birth*Is the Patient the person responsible for paying for care?* Yes No Person Responsible for Paying Bill (if not the patient)* First Last Person Responsible for Paying Bill Date of Birth*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account Number(s)*Submit DocumentsUse the box below to submit additional documents for your financial assistance application. Common documents include: pay stubs, bank statements, tax returns, and other income statements (self-employment records, unemployment, alimony/child support, Social Security, pension/retirement, etc.). Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 30 MB, Max. files: 10. Great! Please do not close your browser or leave this page until you see the confirmation page.
