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, without charge to qualifying individuals. 

To qualify, patients must complete a financial assistance application and meet the following guidelines: 

  • 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:

FAMILY SIZE

2025 Care Assurance Income Guidelines

2026 Care Assurance Income Guidelines

1

$15,650

$15,960

2

$21,150

$21,640

3

$26,650

$27,320

4

$32,150

$33,000

5

$37,650

$38,680

6

$43,150 

$44,360

7

$48,650

$50,040

8

$54,150

$55,720

Each additional person

Add $5,500

Add $5,680

 

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, without charge, to individuals from households with incomes up to 400% of the Federal Poverty Guidelines for uninsured patients and up to 200% of the Federal Poverty Guidelines for insured patients. This 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