Financial Assistance

Monday – Friday,  7:00 a.m. to 4:30 p.m.



We welcome your phone calls and/or emails with any questions.  Our office hours, direct phone number and email address are listed above.

If you do not have health insurance or are underinsured, we invite you to apply for financial assistance.  You may be eligible for a full write off under the State of Ohio’s Hospital Care Assurance Program (HCAP) or for discounted rates under our own CHWC Financial Assistance Program.  You can learn more by clicking on the link below for a  “Plain Language Summary”.  We also have links for the financial application, income level breakdown, Financial Assistance Policy and Billing and Collections Policy.”

Our application for financial assistance is used to determine eligibility for both programs.  You can download and print the application below.  Fill out the application completely and either bring it in person to CHWC or mail it to CHWC.  You will need to include with the application proof of your income for at least the most recent three (3) months, or twelve (12) months prior to your services.  You will also need to include proof of cash assets.

Our patient representatives will use the information from your completed application and proof of income to determine your eligibility for assistance (based on each program’s criteria at the time of service).

You can deliver in person, or MAIL completed applications to:

CHWC Patient Accounts

433 W. High Street

Bryan, Ohio 43506

Here are our online and clickable forms and policies:


Financial Assistance Application Form

Financial Assistance Policy

Financial Collection Policy