Financial assistance application document checklist
To complete your Financial Assistance Application, please review this checklist.
Provide copies of the following documents
- Proof of Residency in Santa Clara County – Provide ONE of the following:
- Rental Contract/Lease
- Mortgage Statement
- Utility Bill (Water, Electric Gas, Garbage)
- Homeless (Completion of patient statement form)
- Vehicle Registration
- Driver License (Current)
- Letter of support from person with whom applicant is living and proof of residency for that person
- Proof of Identity (Photo ID Required) – Provide ONE of the following:
- Driver’s License
- Passport
- Government-issued ID Card
- Work or School ID Card
- Birth Certificate along with any identification (such as gym/Costco)
- Proof of Income – Provide ALL that Apply:
- Check Stubs (all stubs not older than 45 days from application date)
- Tax Return (current tax year)
- Award Letter (Social Security, Disability, Unemployment, Worker’s Compensation)
- Cash Income Statements (including tips)
- Military Benefits Statement
- Rental Income Receipts
If required – these documents must be originals:
- Eligibility for some programs requires that a person provides proof of U.S. Citizenship or U.S. Permanent Residency. If you are eligible for a program that requires proof of citizenship or permanent residency, you will be instructed to bring original documents. Copies will not be accepted. Undocumented individuals may be eligible for programs that do not require proof of U.S. Citizenship or U.S. Permanent Residency.
- Depending on a person’s declarations and/or differences in documentation, additional documents may be required. If more documents are required, you will be instructed which documents to provide. You will also be given a deadline for returning additional documents to the Patient Access Department.