Financial Assistance Application

Provider Listing

A Notice to Our Patients

Dear Patient, 

The Federally funded Ohio Hospital Care Assurance Program and Western Reserve Hospital Financial Assistance Programs apply to hospital charges only.  These programs do not include any Physician services or professional billing fees.  

Western Reserve Hospital will provide basic, medically necessary hospital care, *free of charge to qualifying individuals.  To be considered eligible, you must: 

  • Be a resident of Ohio
  • Not be currently enrolled in Medicaid
  • Be an individual or from a family whose income is at or below the Federal Poverty Income Guideline listed below:


2022 Care Assurance Income Guidelines

2023 Care Assurance Income Guidelines

























Each additional

Add $4,720

Add $5,140

Three-Year Application Deadline - The free care requirement was first imposed on May 22, 1992. Note that only patients served after December 14, 2000 are bound by the three-year application deadline. Hospitals must still accept application at any time from a patient served before December 14, 2000.

Western Reserve Hospital Financial Assistance Program - This program is not funded and is exclusive to Western Reserve Hospital. Western Reserve Hospital's administration approved this program to provide basic, medically necessary care free of charge to individuals from families whose house hold income is marginally above the Federal guideline to up to 400% the Federal guideline. (Program is subject to cancellation or change at any time)

To apply, please complete and sign the application. In order for us to process your application in a timely manner, you must provide the required information. Mail your completed application to the address below. Written notification of approval or denial will be mailed to you.  If you have future services, you will be required to submit a new application. 

For additional information please call Customer Service at (330) 255-3101.                         

Western Reserve Hospital
Attn: Patient Financial Services
1900 23rd Street
Cuyahoga Falls, Ohio  44223