Financial Assistance

Geisinger is commited to providing healthcare to those in need, regardless of their ability to pay.
To find out if you are eligible for Geisinger’s uncompensated care program, print this form (pdf) and complete all the items using n/a if the information does not apply. Upon completion of the form, please review the information for accuracy, sign the form and return it via surface mail with the other applicable information outlined below to:


Geisinger Health System
Attn: Uncompensated Care Unit 49-38
1 Geisinger Medical Center
Danville, PA 17822-0002

Applications with incomplete/missing information will be returned and could result in a denial  If items are left blank, it will cause a delay in processing as the form will have to be returned to you for completion. Include all medical record numbers in the space provided in the lower left hand corner under the title “Account Number.”

In addition to returning the completed application, be sure to attach the documents listed below for all household members:

The types of proof of income to be returned with the complete financial statement vary. Include all items below that apply to you:

Employed – Copies of the four most recent pay stubs for the income(s) of all members of the household. If this is not available, a letter from your employer on their letterhead outlining the same information is acceptable.

Unemployment Compensation - Copy of the eligibility determination letter must be submitted.

Unemployed - If no income exists, a notarized letter stating there is no income being received from any source is required.

Social Security Recipient – A copy of the current year’s benefit determination letter is acceptable.

Disability Recipient – A copy of the Benefit Determination letter is acceptable.

Pension Recipient - Copy of pension check or a letter from the pension’s source stating the dollar amount of the monthly benefit.
In the event a Medical Assistance application has been submitted recently and rejected, a copy of the rejection letter (in addition to any other previously listed information that may apply) is requested. 

Note: Guidelines for Geisinger-Bloomsburg Hospital differ from those of the rest of Geisinger Health System. Geisinger-Bloomsburg Hospital patients should follow the guidelines here (pdf).

If you have any questions or need help completing the statement, contact the Patient Service Call Center at 1-800-468-7201

Financial assistance policy

You are responsible for applying for financial assistance. Geisinger Health System will make application materials easily available. To request an application, call 1-800-468-7201.