How to Apply

Fill Out an Application

Download and print the Financial Assistance application (select your language). Forms are also available at our Registration Department and Cashier’s Office.

CHARITY APPLICATION – ENGLISH

CHARITY APPLICATION – ENGLISH / SPANISH

Submit Your Application

By Mail:

Alhambra Hospital Medical Center
Attn: Business Office Department
100 S. Raymond Ave.
Alhambra, CA 91801


In Person:

Alhambra Hospital Medical Center
Attn: Business Office Department
100 S. Raymond Ave.
Alhambra, CA 91801

Need help getting the application, filling it out or turning it in?

Contact the Business Office Department at (626) 457-7997.

For patients currently admitted at the hospital, contact the Quality Control Coordinator at (626) 458-4718.

Application Review

Upon receipt of the application, the application is reviewed by staff at the Business Office Department to determine if the application has been completed and the supporting documents are attached.

The patient will continue to receive statements, but will not be sent to a collection agency during the review process.

If the application is incomplete, the patient is sent a letter requesting the missing information.

The patient is given 15 days to return the requested information.

If the requested information is not received within 15 days, the patient will be called before canceling the Charity application.

Once the application is complete, the application is forwarded to the Business Office Director for determination.

If the application is approved, the patient will be sent an approval letter.

If the application is denied, the patient will be sent a denial letter with explanation.

The Business Office Director will make every reasonable effort to make the Charity Care determination as soon as possible.