About You

The first page of the application provides Providence with information about you.

You will be asked to answer important questions about yourself and your experience. We ask for your contact information and employment status because each state provides different levels of assistance based on these and other criteria. We take your privacy seriously and this information will remain confidential.

Start your application now or get step-by-step support completing it on these pages.

Download Application

Screening Information

These questions help us understand how we might support you better. Based on your answers, a financial counselor may be able to help you explore government or community programs, in addition to financial assistance from Providence.

Patient and Applicant Information

Here, you’ll provide your contact information and employment status.

Person responsible for the bill

List any patients over 18 in your household as responsible for their own bills.

For children under 18, list a parent or legal guardian as responsible for paying. Note that only people considered members of your family—members of the household who are related by blood or law—should be listed.

Form field for person responsible for paying bill

Patient social security number

You don’t need a Social Security number to apply; it’s optional and confidential.

We also don’t use Social Security numbers for anything beyond identification. It helps us make sure we have the right person if another patient has a name or date of birth close to yours.

Application field for patient social security number

Mailing address

If you don’t have a permanent address at the moment, just note “N/A” here. Be sure to leave us a phone number or email address where we can reach you.