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.
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)
Forms - Español
Política de Asistencia Financiera - Español (PDF)
Lineamientos Federales De Pobreza - Español (PDF)
Resumen de Asistencia Financiera Para Pacientes - Español (PDF)
Solicitud de Ayuda Económica - Español (PDF)
Forms - Gujarati
Financial Assistance Policy - Gujarati (PDF)
Forms - Japanese
Financial Assistance Policy - Japanese (PDF)
Amounts Generally Billed - Japanese (PDF)
Federal Poverty Guidelines - Japanese (PDF)
Forms - Laotian
Financial Assistance Policy - Laotian (PDF)
Amounts Generally Billed - Laotian (PDF)
Federal Poverty Guidelines - Laotian (PDF)