Financial Assistance Program

We’re Here for You

As part of our commitment to serving our community, Weiss Memorial Hospital provides financial assistance to patients who are in financial need and meet certain requirements. Although the Financial Assistance Program does not help with medical bills for doctor services, it may provide help for other medical bills. To determine if you qualify for financial assistance, we need to obtain certain financial information. Cooperating with this request for financial information allows us to give all due consideration to your request for financial assistance.

If you’re uninsured, a Social Security Number is not required to qualify for free or discounted care, but is required for certain public programs like Medicaid. Providing a Social Security Number isn’t required, but does help us determine if you’re eligible for any public programs.

Financial Assistance Application

Verification of Income

To consider your request for financial assistance, we need verification of income. Please provide a copy of the following documents:

• Governmental assistance, Social Security, Workers Compensation or Unemployment Compensation Determination Letter
• Income tax return for previous year

Please also include one or more of the following:

• IRS Form W-2, Wage and Earnings Statement for all household earnings
• Last two paycheck stubs for all household earnings
• Bank statement that contains income information

If you’re unable to provide income verification, please contact our office for further instructions. Applications without verification are incomplete and will not be processed.

Submitting Your Application

Please return the completed application and verification of income within seven days to:

Weiss Memorial Hospital
4646 North Marine Drive
Chicago, IL 60640
Attn: Financial Counseling

We will notify you of your eligibility following receipt and review of all necessary information. Notification will be mailed to the mailing address you have provided on your Financial Assistance Application.