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Financial Assistance Program

Memorial Hermann Health System’s Financial Assistance Policy and Admissions Policy govern how financial assistance is provided.  On the basis of these policies, a determination will be made regarding a patient’s eligibility for financial assistance.

Payment from all other possible payment sources must be exhausted before a patient can be considered for the financial assistance program.  For patients who do not have insurance coverage, alternate funding and payment plan options may be available. Our staff or contracted agents work with patients to identify potential options.

Financial assistance may be available to patients who do not have the means to pay for their healthcare expenses and do not qualify for any government or other programs. A patient may qualify for Financial Assistance based on federal poverty guidelines.

To be considered for this program, patients are required to provide financial information for the household by completing a Financial Information Form along with supporting documentation.  To verify income, the most current Federal Income Tax Return should be provided.  Other pieces of supporting documentation may be requested in addition to or instead of the Tax Return, including:  Last two Employer paycheck stubs, written documentation from income sources, and a copy of all bank statements for the last three months. Memorial Hermann reserves the right to review an applicant’s credit report, property tax records, and/or other public or personal documents prior to a determination regarding program eligibility. Please see policy for specific locations and services covered by our Financial Assistance Policy. Not all locations and services listed on our website are covered by the Financial Assistance Policy.

To request a Financial Information Form, please contact our Customer Service Department at 713.338.5502 or see the forms section below.

List of providers not covered under MHHS’s Financial Assistance Policy

Provider list (CSV format)

Provider list (HTML format)

Forms - Amharic

በቀላል ቋንቋ የተዘጋጀ አጭር መግለጫ - Amharic (PDF)

የገንዘብ ድጋፍ ማመልከቻ - Amharic (PDF)

የክፍያ አጠያየቅ እና አሰባሰብ ፖሊሲ - Amharic (PDF)

Forms - Arabic

سياسة شركة ميموريال هيرمان للرعاية الصحية - Arabic (PDF)

المستند أ حساب المبالغ المفوترة بشكل عام - Arabic (PDF)

المستند ب المبادئ التوجيهية الفيدرالية لتعريف الفقر- Arabic (PDF)

ملخص اإلعانة املالية املُقدمة للمريض - Arabic (PDF)

استمارة معلومات مالية - Arabic (PDF)

سياسة تحرير الفواتير والتحصيل - Arabic (PDF)

خدمات الترجمة 800-846-5197 Client ID: 555004

Forms - Bengali

আিথর্ক সাহাযয্ নীিত - Bengali (PDF)

প্লেইন ল্যাঙ্গুয়েজ সামারি - Bengali (PDF)

আিথক সাহােযর আেবদন - Bengali (PDF)

লব্লিং অযান্ড কালিকিন্স পলিলস - Bengali (PDF)

Forms - Chinese

財務援助政策 - Chinese (PDF)

附表A - 一般計費金額計算 - Chinese (PDF)

附表B - 聯邦貧困層級指引 - Chinese (PDF)

患者財務 援助摘要 - Chinese (PDF)

財務援助申請 - Chinese (PDF)

收費與收款政策 - Chinese (PDF)

翻譯服務 Mandarin 855-670-9799 Client ID: 555004

翻譯服務 Cantonese 855-745-1360 Client ID: 555004

Forms - English

Financial Assistance Policy - English (PDF)

Amounts Generally Billed - English (PDF)

Federal Poverty Guidelines - English (PDF)

Patient Financial Assistance Summary - English (PDF)

Financial Assistance Application - English (PDF)

Billing and Collection Policy - English (PDF)

Translation Services 713-338-5502

Forms - Español

Política de Asistencia Financiera - Español (PDF)

Cálculo de los Importes Generalmente Facturados - Español (PDF)

Lineamientos Federales De Pobreza - Español (PDF)

Resumen de Asistencia Financiera del Paciente - Español (PDF)

Solicitud de Ayuda Económica - Español (PDF)

Política de Facturación y Cobro - Español (PDF)

Servicios de traducción 855-583-2102 Client ID: 555004

Forms - Farsi

سیستم سیاست بهداشتی مموریال هرمان - Farsi (PDF)

مدرک A محاسبه مبالغ معمول صورتحساب - Farsi (PDF)

مدرک B دستورالعملهای فدرال فقر - Farsi (PDF)

خالصه کمک مالی به بیمار - Farsi (PDF)

فرم اطلاعات مالی / درخواست کمک مالی - Farsi (PDF)

سیاست صدور صورتحساب و وصول - Farsi (PDF)

خدمات ترجمه 855-745-1355 Client ID: 555004

Forms - Formosan

財務協助政策 - Formosan (PDF)

財務協助申請書 - Formosan (PDF)

計費及收款政策 - Formosan (PDF)

Forms - French

Politique d’aide financière - French (PDF)

Annexe A – Calcul des montants généralement facturés - French (PDF)

Annexe B – Directives fédérales sur la pauvretév - French (PDF)

Présentation de l’Assistance Financière des Patients - French (PDF)

Demande d'aide Financière - French (PDF)

Politique de Facturation et de Recouvrement - French (PDF)

Services de traduction 800-892-0564 Client ID: 555004

Forms - German

Beihilferichtlinie - German (PDF)

Anhang A – Berechnung der normalerweise berechneten Beträge - German (PDF)

Anhang B – Federal Poverty Guidelines - German (PDF)

Finanzielle Unterstützung für Patienten – Übersicht - German (PDF)

Antrag auf finanzielle Unterstützung - German (PDF)

Richtlinie zu Rechnungsstellung und Inkasso - German (PDF)

Übersetzungsdienstleistungen 855-745-1356 Client ID: 555004

Forms - Gujarati

મેમોરિયલ હિમૅન હલ્થે સિસ્ટમ નીસિ - Gujarati (PDF)

પુરાવો A - બિલની સામાન્ય રકમની ગણતરી - Gujarati (PDF)

પુરાવો B - સંઘીય ગરીબીના નનર્દેશો - Gujarati (PDF)

દર્દી માટેઆર્થિક સહાયતાનો સાર - Gujarati (PDF)

નાણાકીય સહાય એપ્લિકેશન - Gujarati (PDF)

લિલલિંર્ અને વસૂલાતની નીનત - Gujarati (PDF)

ભાષાંતર સેવા  855-745-1357 Client ID: 555004

Forms - Hindi

वित्तीय सहायता पॉलिसी - Hindi (PDF)

प्रतिदर्श A - सामान्यिः बिल की गई राशर्योँ की गणना - Hindi (PDF)

प्रतिदर्श B - संघ तिर्शििा ददर्ातिदेर् - Hindi (PDF)

रोगी वित्तीय सहायता सारांश - Hindi (PDF)

वित्तीय सहायता आिेदनपत्र - Hindi (PDF)

त्रबशलिंग एविं सिंग्रहण िीतत - Hindi (PDF)

अनुवाद सेवाएं  855-745-1354 Client ID: 555004

Forms - Igbo

Ego onye ọrịa Nchịkọta enyemaka - Igbo (PDF)

Enyemaka Enyemaka Ego - Igbo (PDF)

Iwu ịgba-ụgwọ na nnakọta - Igbo (PDF)

Forms - Japanese

資金援助方針 - Japanese (PDF)

通常請求額計算 - Japanese (PDF)

連邦貧困ガイドライン - Japanese (PDF)

患者資金 援助要旨 - Japanese (PDF)

費用補助申請書 - Japanese (PDF)

請求および回収ポリシー - Japanese (PDF)

翻訳サービス 855-745-1359 Client ID: 555004

Forms - Korean

재정 지원 정책 - Korean (PDF)

증빙 서류 A - 일반 청구 금액(AGB) 계산 - Korean (PDF)

증빙 서류 B - 연방 빈곤 지침 - Korean (PDF)

환자 재정 지원에 관한 요약 안내 - Korean (PDF)

재무 정보 양식 / 재정 지원 신청서 - Korean (PDF)

청구 및 추심 정책 - Korean (PDF)

번역 서비스 855-751-2050 Client ID: 555004

Forms - Kru

Financial Assistance Policy - Kru (PDF)

Financial Assistance Brochure - Kru (PDF)

Financial Information Form and Application - Kru (PDF)

Billings and Collections Policy - Kru (PDF)

Forms - Laotian

ນະໂຍບາຍການຊ່ວຍເຫຼືອດ້ານການເງິນ - Laotian (PDF)

ການຄິດໄລ່ຈໍານວນເງິນທີ່ອອກໃບບິນທົ່ວໄປ - Laotian (PDF)

ຄູ່ມືກ່ຽວກັບຄວາມທຸກຍາກຂອງລັດບານກາງ - Laotian (PDF)

ລວມການຊ່ວຍເຫຼືອ ດ້ານການເງິນໃຫ້ແກ່ຄົນເຈັບ - Laotian (PDF)

ແບບຟອມຂໍ້ມູນທາງດ້ານການເງິນແລະການນໍາໃຊ້ - Laotian (PDF)

ນະໂຍບາຍກ່ຽວກັບການອອກບິນເກັບເງິນ ແລະ ການເກັບເງິນ - Laotian (PDF)

ບໍລິການແປພາສາ 855-869-9088 Client ID: 555004

Forms - Malayalam

സാമ്പത്തിക സഹായ നയം - Malayalam (PDF)

സാമ്പത്തിക സഹായം ഫോം - Malayalam (PDF)

Forms - Nepali

आथर्क सहायता नीित - Nepali (PDF)

सरल भाषा सारांश - Nepali (PDF)

सहायता आवेदन - Nepali (PDF)

बिलिंग और संग्रह - Nepali (PDF)

Forms - Mon-Khmer

គាលនេយាបាយសពីជំនួយហិរវត - Mon-Khmer (PDF)

សេចក្ដីសង្ខេបអំពីជំនួយ - Mon-Khmer (PDF)

ទរមង់ែបបបទព័ត៌មានហិរញញវតថុ - Mon-Khmer (PDF)

វិក័យប័ត្រនិងការប្រមូល - Mon-Khmer (PDF)

Forms - Portuguese

Política de assistência financeira - Portuguese (PDF)

Solicitação de Assistência Financeira - Portuguese (PDF)

Política de faturação e cobrança - Portuguese (PDF)

Forms - Russian

Политика финансовой помощи - Russian (PDF)

Приложение А — Расчет средней суммы счеBusiness Assistanceта - Russian (PDF)

Приложение B – Федеральный прожиточный минимум - Russian (PDF)

Краткое изложение Программы финансовой помощи пациентам - Russian (PDF)

Заявление на получение финансовой помощи - Russian (PDF)

Политика выставления счетов и сбора платежей - Russian (PDF)

Переводческие услуги 855-745-1358 Client ID: 555004

Forms - Tagalog

Patakaran sa Pinansyal na Tulong - Tagalog (PDF)

Pagkalkula sa Mga Halagang Karaniwang Sinisingil - Tagalog (PDF)

Mga Alituntunin sa Kahirapan ayon sa Pederal - Tagalog (PDF)

Buod ng Tulong Pinansyal ng Pasyente - Tagalog (PDF)

Form ng Impormasyon at Aplikasyon sa Pananalapi - Tagalog (PDF)

Patakaran sa Paniningil at Pangongolekta - Tagalog (PDF)

Mga Serbisyo sa Pagsasalin 800-892-0549 Client ID: 555004

Forms - Telugu

ఆర్థిక సహాయం విధానం - Telugu (PDF)

ఫైనాన్షియల్ అప్లికేషన్ ఫారం - Telugu (PDF)

బిల్లులు మరియు సేకరణలు విధానం - Telugu (PDF)

Forms - Thai

นโยบายความช่วยเหลือด้านการเงิน - Thai (PDF)

แบบฟอร์มทางการเงินและการสมัคร - Thai (PDF)

นโยบายการเรียกเก็บเงินและการเรียกเก็บหนี้ - Thai (PDF)

Forms - Urdu

مالیاتی اعانت کی پالیسی - Urdu (PDF)

شہادتی اشیاء A عام طور پر بل کردہ رقم کا حساب - Urdu (PDF)

شہادتی اشیاء B غربت کے وفاقی رہنما خطوط - Urdu (PDF)

مالیاتی اعانت کا خالصہ برائے مریض - Urdu (PDF)

مالیاتی معلومات فارم / مالیاتی اعانت کی درخواست - Urdu (PDF)

بلنگ اور وصولی کی پالیسی - Urdu (PDF)

ترجمہ کی خدمات  800-873-1716 Client ID: 555004

Forms - Vietnamese

Chính Sách Hỗ Trợ Tài Chính - Vietnamese (PDF)

Phụ Lục A - Tính Toán Các Khoản Thường Phải Trả - Vietnamese (PDF)

Phụ Lục B – Quy Định Mức Nghèo Liên Bang - Vietnamese (PDF)

Tóm Tắt Hỗ Trợ Tài Chính Cho Bệnh Nhân - Vietnamese (PDF)

Đơn Xin Hỗ Trợ Tài Chính - Vietnamese (PDF)

Chính Sách Thanh Toán và Thu Nợ - Vietnamese (PDF)

Dịch vụ Dịch thuật 855-583-2103 Client ID: 555004

Forms - Yoruba

Òfin Ìrànlọ́wọ́ Owó - Yoruba (PDF)

Iwe ifowopamọ owo-owo - Yoruba (PDF)

Òfin Ìdíyelé àti Gbígbà - Yoruba (PDF)