Get ready to apply
Intermountain Health
Financial Assistance — Colorado, Montana and Wyoming
What you get
Reductions in hospital, clinic, or doctor bills based on income or medical hardship. Open now.
- Who starts it
- You
- How it’s sent
- Email to Peaks_financialassistanceapps@imail.org, or by post
- Your time
- About 30 minutes
- Last checked
- Aug 27, 2026
Before you start, check you fit
- Exact campus, service-area, cost, scheduling, and capacity details may not be published.
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What their form asksA preview, so you can gather things first. Fill it in on their site.
Open the application PDF ↗ Checked Aug 27, 2026Send it by email to Peaks_financialassistanceapps@imail.org.
What the form asks for
Financial assistance application answersAccount numberNumber of people in householdAre you experiencing homelessnessApplicant/patient full nameDate of birthSocial Security numberMailing addressPhone numberEmail addressMarital statusEmployer name and contact informationSpouse and dependent names, relationships, dates of birth, and Social Security numbersEmployment income and pay frequency for each household memberOther household income, including benefits, support, pensions, unemployment, or rental incomeHealth insurance, Medicare, Medicaid, CHIP/CHP+, or other coverageIs this care related to an accident, crime-victim claim, or third-party responsibilityIs anyone in the household pregnantIf needed, explain further why you are requesting financial assistanceI certify that the information supplied is true and completeApplicant signature and dateHave ready
- Completed, signed, and dated financial assistance application.
- Current household income verification, such as recent pay stubs, employer verification, or benefit award statements.
- Profit-and-loss statement, ledgers, or other current records if anyone in the household is self-employed.
- Most recent tax forms or tax return if requested or used as income verification.
- Medicaid denial or eligibility documentation when applicable.
After you send
Respond if a financial counselor requests clarification or additional documentation. Keep a copy of the submission and the determination letter. If you have not heard back in two weeks, write and ask whether it arrived.