Submit a Financial Assistance Determination Appeal "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.List of CommonSpirit Health location(s) where patient was treated.*Patient Name* First Middle Last Patient Date of Birth*Is the Patient the person responsible for paying for care?* Yes No Person Responsible for Paying Bill (if not the patient):* First Last Person Responsible for Paying Bill Date of Birth*Address* Street Address City State Zip Phone NumberPatient Account Number(s)*Date of Determination LetterReason for the DenialPlease provide why you believe your initial financial assistance determination was incorrect.Document UploadPlease upload documents such as pay stubs, bank statements, tax returns, and other income statements to support your appeal. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 30 MB. Please do not close your browser or leave this page until you see the confirmation page.
