Arizona Financial Assistance Program for Discounted and Charity Care

Eligibility for financial assistance is based on household income if: (1) the patient’s annual household income and household size is equal to or less than 400% of the Federal Poverty Level; or (2) medical expenses, including both Banner and non-Banner services, exceed 50% of their household income. The amount of assistance will be approved on a sliding scale depending on household income and all medical expenses. 

Spanish and other translations of Banner's Financial Assistance documentation are available in the admitting area. They may also be requested by contacting Banner Health at (888) 264-2127. 

Any questions regarding the Banner financial assistance programs, or you need help establishing a payment arrangement please contact us at (888) 264-2127 Monday through Thursday 8 a.m. – 7 p.m.; Friday 8 a.m. – 5 p.m.; Saturday 8 a.m. – 12 p.m. (all times are MST).  Learn more about payment plans and financing options.

How To Apply

1. Choose an Application Form below.
2. Fill out all required information and attach supporting documents.
3. Send your completed form by mail or email to the address provided on the Application Form.

Arizona Application Forms

• Hospital Application Form and Summary of Financial Assistance Programs - English (Spanish)
  • Financial Assistance Policy (Excludes California) - English (Spanish)
• Financial Assistance Information in other languages

Additional Financial Assistance Information

• Financial Assistance Information for Physician, Home Care or Imaging Bills
  • Patient Policy - English (Spanish)
  • Plain Language Summary - English
• Financial Assistance Information for Banner Rehabilitation Hospital Bills
  • Patient Policy and Plain Language Summary
• Financial Assistance Information for Banner Surgery Center Bills
  • Patient Policy and Plain Language Summary