Financial Application Instructions

If you are unable to meet the required payment arrangement on your account due to a permanent or temporary financial situation, you may have your account reviewed by WakeMed to determine if you qualify for alternative arrangements. To begin the process, complete the financial statement form available and submit the following information along with your application:

  • Most recent Tax Return for Guarantor/Patient and spouse (to include all copies of 1040 Form, 1040 EZ Form, etc.)
  • Most recent pay stub(s) for Guarantor/Patient and spouse (must show work history for past 4 weeks)
  • Last 3 months bank statements (with ALL pages)
  • Disability letter – if applicable
  • Medicaid Denial letter – if applicable
  • Social Security Benefit statement - if applicable
  • All sources of household income (child support, alimony, etc.)

Proof of Permanent Residency - Any of the following will be accepted:

  • Mortgage Statement, Rental Agreement, Visa or Passport, Current Electric Bill, Current Phone Bill (The required documents showing proof of residency may also be in the spouse's name, but must match the address listed for the patient/guarantor.)

If all of the requested documentation is not received within 30 days from your application date, the review for financial assistance will close and normal billing procedures will continue. Upon receipt and review of your application, and all of the required documentation listed above, WakeMed may contact you regarding any alternate payment arrangements that can be made on your account. Until you have received written notification from WakeMed regarding a change in payment arrangements, please continue to make the required payments.

To ensure that the information is received promptly, please return completed application with required documentation to either of the below pathways:

By Mail:

PFS - Customer Service Unit
P.O. Box 14465
Raleigh, N.C. 27690-2002

By Fax:
Fax: (919) 350-6580
*Please send both sides if copies are front and back

Financial Assistance Applications

Financial & Charity Care Policies

Read WakeMed's Patient Billing Information & Financial Policy  English | Spanish 

Read WakeMed's Charity Care Policy  English | Spanish

Read WakeMed's Charity Care Policy Summary English | Spanish

 

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