CHWC has two programs that offer financial aid to pay for hospital services. The first program is part of the Hospital Care Assurance Program (HCAP) through the State of Ohio, which mandates that hospitals offer free care to any patient who is an Ohio resident and whose annual income is at or below the federal poverty level. This program excludes Home Health, Hospice, and Long-Term Care.

To apply for financial assistance:

A completed Financial Assistance Application must be submitted, either in person or by mail, to CHWC with proof of your income for the 3 months or 12 months prior to your service. Your Patient Representative will use this information to verify your HCAP eligibility based on Federal poverty levels at the time of your service.

Return your completed application to:
CHWC Patient Accounts
433 W High Street
Bryan, OH 43506

To print a blank application:  CLICK HERE TO PRINT the Financial Assistance Application. To complete the online form below, fill in the fields and print it out. 

(Return to Business Office) Date :  
Patient Name:
Date Of Birth:
Phone #:
Applicant Name:
Applicant Email:
Spouse Name:
Date(s) of Hospital Service:
1. Were you an Ohio resident at the time of your hospital service?  Yes No
2. Did you have Medicaid or disability assistance at the time of service?  Yes No
3.Did you have health insurance or other auto/liability insurance at the time of service?  Yes No
(Please attach a copy of any DA, Medicaid, or Insurance card that has not paid on this bill.)
Please provide the following information for all the people in your immediate family who live in your home. For purposes of HCAP, “family” is defined as the patient, patient’s spouse, and all of the patient’s children under 18 (natural or adoptive) who live in the patient’s home. Income includes wages, self employment, social security, unemployment, child support, alimony, workers comp, pension, VA benefits, food stamps, etc. For patients under 18, include parental income. If zero income is reported, provide an explanation of how the patient is supporting himself/herself.:
Name Age Relationship
To Patient
Gross Income 3
Months Prior To
Date of Service
Gross Income 12
Months Prior To
Date of Service
Type of Income
Attached *
Please provide income verification with this application
*Preferred Income Verification: Pay stubs or employer printouts for requested months; income tax returns and W2s can be used for some accounts.
If you do not have a checking or savings account, please state “NONE” accordingly in the space provided.

4. Checking Account Balance Where is your account?
5. Savings Account Balance Where is your account?
6. Current monthly gross income for all family members living in home
(Additional information to assist CHWC in determining your financial need can be noted on the back of the printed form)
Financial assistance provided by CHWC may be reversed if the information is not correct. Providing false information to induce another to extend credit or to bestow any other valuable benefit may be a violation of the Ohio Revised Code Section 2921.13.
By my signature below I affirm the information on this application is true to the best of my knowledge. (Please sign and date the completed application AFTER you print it)  
Signature Date
Print your completed application and bring it to Bryan Hospital, or mail to:

Patient Accounts Department
433 W. High Street
Bryan, OH 43506

If you do not qualify for HCAP, we will process the application under the CHWC Charitable Discount Program. Based on the information you provide on the application, you may be eligible for a 30, 70 or 100% discount on your outstanding hospital balance.

Please  return your completed application to: CHWC Patient Accounts 433 W High Street Bryan, OH 43506

If you have any questions on either of these programs, please contact your Patient Representative at 419-630-2149, Monday through Friday 7:00 a.m. to 4:30 p.m.