Financial Assistance

Financial assistance is available for patients who receive medically necessary services and meet the eligibility requirements under the policy. If eligible for financial assistance, patients will receive a 100 percent discount or free care. The financial assistance program does not cover elective services.

In order to qualify for financial assistance, all of the following conditions must be met:

The patient must be uninsured or, in certain circumstances, have limited insurance coverage
The patient must be unable to access other programs that would cover medical expenses
The patient's annual family income must be no more than 300 percent of the current year Federal Poverty Guidelines
The patient must not have substantial cash assets
The patient must not have declined health insurance through an employer
The patient must not be ineligible for government sponsored coverage because of noncompliance with requirements
The service must be considered medically necessary (generally defined as urgent or emergent)
The patient must reside within a 25-mile radius of the facility where services are rendered
The completed application and all supporting documentation must be submitted to the Patient Account Services department, during the applicable time period, for review and approval

Calling the toll-free Customer Service number at 877-442-2989
Calling the toll-free Customer Service number on the front of your statement and requesting the Financial Assistance Application (copies will be mailed at no charge)
Emailing a request to charitycare@patientfinancialsvcs.com

For your convenience, you can download directly from this site, the Required Documentation checklist, the Financial Assistance Policy and the Financial Assistance Application.

Click here for required documentation

Financial Assistance Application - English
Financial Assistance Application - Spanish

Once all requested documents are received, the application will be reviewed. An approval or denial letter will be mailed to each applicant. The Financial Assistance Application and documentation must be updated every six months, or when the patient’s income or other key circumstances change. Each visit within the six month period is subject to be reviewed.

This policy does not apply to services rendered by independent physicians or practitioners that are not employed by UVA Health Outpatient Imaging Centreville. This includes, but is not limited to, anesthesiologists, radiologists, and pathologists.

No individual who is eligible for financial assistance will be charged more than amounts generally billed for emergency or other medically necessary care to individuals who have insurance covering such care.