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
complete application within 90 days of service.
Please note: Financial assistance policy does not apply to:
a. Patients with a Medi-Cal Share of Cost
b. Future services are not accepted; services must be rendered before
application can be processed.
c. Out of county residents are elibible for emergency cases only.
d. Sequoia Prompt Care services are not applicable.
e. Separately billable physician services such as a primary care physician
or California Emergency Physicians (Emergency Room Physicians)