Help Paying Your Bill

Financial Assistance

Pomona Valley Hospital Medical Center (PVHMC) strives to meet the health care needs of all patients who seek inpatient, outpatient and emergency services. PVHMC is committed to providing access to financial assistance programs when patients are uninsured or underinsured and may need help in paying their hospital bill. These programs include government-sponsored coverage programs, charity care and discount payment as defined.

Do I qualify for Financial Assistance?

Charity Care: Financial assistance is available to patients who are unable to pay their hospital bill due to a financial inability to pay. This is available to patients receiving medically necessary services and who meet the qualifications of the hospitals Charity Care Financial Assistance Policy.

Discounted Care: Patients who are not eligible for charity care due to the patient’s family income is greater than 400% of the established Federal Poverty level are eligible for discounted care.

Eligibility for financial help is determined without regard to sex, race, color, religion, ancestry, national origin, age, disability, medical condition, marital status, sexual orientation, gender identity, gender expression or educational background.

Then, mail your application and supporting documents to: Pomona Valley Hospital Medical Center, Attn:
Eligibility Services, 1798 N. Garey Ave, Pomona, CA 91767. For questions regarding this form, please call: 909.469.9441.

HHS Poverty Guideline for 2024

Person in Family/Household	Poverty Guideline
1	$15,060
2	$20,440
3	$25,820
4	$31,200
5	$36,580
6	$41,960
7	$47,340
8	$52,720
For families/households with more than 8 persons, add $5,380 for each additional person.

Source: https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

2024 poverty guidelines for the 48 contiguous states and the District of Columbia are in effect as of January 17, 2024.

How to Apply and Financial Assistance Documents

To view our Charity Care Financial Assistance Policy and Charity Care Application, click on the PDF files below. Please download, print and complete the application and attach copies of the following documentation, as applicable:

To determine eligibility, the following documentation is required, when applicable:
- Charity Care:
  - Completed & signed ﬁnancial assistance application;
  - Current pay stubs from the last two pay periods or if self-employed, current year-to-date proﬁt & loss statement to determine current income;
  - Award letters for social security, SSI, Disability, Unemployment, General Relief, Alimony, etc.;
  - Last calendar year’s ﬁled tax return with all required schedules to determine income generating assets including monetary assets;
  - Last two months’ bank, brokerage & investment statements;
  - Copies of prior year’s 1099 for interest income, dividends, capital gains, etc.

Discount Payment: No application required

Then, submit your application and supporting documents to: Pomona Valley Hospital Medical Center Attn: Eligibility Services 1798 N. Garey Ave, Pomona, CA 91767. You may also submit the form in person at the same address, Cashier’s Office, or by e-mail: customer.service@pvhmc.org. For questions regarding these forms, please call 909.865.9100. These forms are also available at our registration and admission offices.

View our Charity Care Statement in other languages, including Arabic, Armenian, Chinese, Farsi, Hindi, Hmong, Japanese, Khmer, Korean, Lao, Punjabi, Russian, Tagalog, Thai, Ukrainian and Vietnamese HERE.

Need help getting the application, filling it out, or turning it in? Contact Business Services at 909.865.9100.

For patients currently admitted to PVHMC, contact Eligibility Services at 909.469.9441.

PVHMC will review your application. A representative will check your application to make sure it is complete and all supporting documentation is provided. If your application is incomplete, you will receive a letter explaining what is needed.
You will receive a determination letter notifying you when your application is approved or declined, which will include a clear explanation of why you were approved or declined.
If you have not received your determination letter or status notifications, you may contact Business Services at 909.865.9100.

What Services are Covered?

PVHMC’s Charity Care and Discount Payment policies apply only to medically necessary services provided by PVHMC. Elective procedures and follow up care are limited to patients who live in PVHMC’s service area or as otherwise approved by an Officer of PVHMC. Doctors who practice at PVHMC and their services are not included in this policy. Doctors with private practice offices are not covered in this policy.

More Help:

Help paying your bill – there are free consumer advocacy organizations that will help you understand the billing and payment process. You may call the Health Consumer Alliance at (888) 804-3536 or go to healthconsumer.org for more information.

Other Assistance Programs:

PVHMC takes part in a number of government aid programs that are not part of PVHMC’s Charity Care and Discount Payment policies:

Medi-Cal
California Victims of Crime Compensation Program
California Health Benefit Exchange (Covered California)

You may also be eligible for subsidized coverage through the California Health Benefit Exchange (Covered California).

Hospital Billing Complaint Program

The Hospital Bill Complaint Program is a state program, which reviews hospital decisions about whether you qualify for help paying your hospital bill. If you believe you were wrongly denied financial assistance, you may file a complaint with the Hospital Bill Complaint Program. Go to HospitalBillComplaintProgram.hcai.ca.gov for more information and to file a complaint.

Need More Help?

If you have questions about financial assistance, we are here to help. Please call 909.865.9100, Monday through Friday, 8:00 a.m. to 4:30 p.m.