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Financial Assistance Program

Sutter Gould Medical Foundation has a financial assistance program for Sutter Gould patients who are uninsured and low income who may not be able to pay their bill.

Patients who submit an application and are approved may be eligible for full or partial write-off of charges.

The Sutter Gould Financial Assistance
Program is designed to:

• Provide charity care to uninsured patients earning up to 200% of the Federal Poverty Income Guideline (FPIG). NOTE: The FPIG is updated each year in February and can be viewed by clicking here.
• Provide catastrophic protection to low income uninsured patients by limiting their liability to 30% of their annual household income.

To apply for financial assistance at Sutter Gould Medical Foundation:

1. Please complete the Statement of Financial Condition (PDF 0.15Mb).
2. Include the following:
   • Your two most recent paycheck stubs;
   • Your two most recent bank statements (all accounts);
   • Your most recent tax return.
3. Mail the packet to:
   • Sutter Gould Medical Foundation
     5225 Wiley Post Way
     Suite 250
     Salt Lake City, UT 84116
   • Or FAX to: 801-575-1255

Copies of our charity care application are also
available by calling 877-351-4875 ext. 51250.

Your Confidentiality is Guaranteed

Confidentiality of information and individual dignity will be maintained for all that seek charitable services. The handling of personal health information will meet all HIPAA requirements.

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