Financial Assistance Application
Please complete all areas of the application form. If any area does not
apply to you, write N/A or "0" in the space provided.
Please note: Financial assistance policy does not apply to:
a. Future services are not accepted; services must be rendered before
application can be processed.
b. Out of county residents are eligible for emergency cases only.
c. Sequoia Prompt Care services are not applicable.
d. Separately billable physician services such as a primary care physician
or California Emergency Physicians (Emergency Room Physicians)