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Financial Hardship Application

Ally Medical is dedicated to supporting the communities and patients it serves. To fulfill this commitment, all emergency care facilities operated by Ally Medical offer financial assistance to eligible patients in accordance with the Ally Medical Financial Assistance Policy.

Eligibility requirements:

All patients can qualify for financial assistance for emergency care. Established discount guidelines are utilized to determine what amount, if any, will qualify for financial assistance.

  • Generally, qualifying patients with family income at or below 300% of the Federal Poverty Guidelines (FPG) will receive a 100% discount.
  • Patients who meet the criteria of having family incomes ranging from over 300% of the Federal Poverty Guidelines (FPG) will receive additional discounts.

How to apply:

Each visit will require a completed application and will be reviewed independently.

Please click on the application link below, and you will be asked to provide the details below:

  • Patient Demographics
  • Date of Service and Location of Services
  • Contact Information
  • Household Income Details to Determine Federal Poverty Guidelines
  • Proof of income such as tax documents, pay stubs, or other pertinent documents.

After you apply:

After you have completed your application, we will reach out to you to notify you of your application status with in 7-10 business days. You may reach us at if you have any questions or need to adjust your application.