Get ready to apply
Intermountain Health
Financial Assistance Program - Primary Children's Hospital
What you get
Reduced charges for eligible medically necessary hospital, clinic and employed-provider care at Intermountain. Open now.
- Who starts it
- You
- How it’s sent
- Email to financial.assistance@r1rcm.com, or by post
- Your time
- About 30 minutes
- Last checked
- Aug 27, 2026
Before you start, check you fit
- Only eligible Intermountain charges and covered employed providers are included.
- A patient may apply after care begins and even after an account reaches collections, subject to policy deadlines.
- The complete sliding-scale table, nominal responsibility, and provider list should be confirmed for each bill.
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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 financial.assistance@r1rcm.com.
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.