Financial Assistance "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Thanks for using our Eligibility Checker for Financial Assistance! Answer the following 3 questions to see if you may be eligible for a discount on your ABC Hospital bills. Including yourself, how many people are in your immediate family?*Please enter a number from 1 to 10.What is your estimated gross MONTHLY household income?*Please enter a number from 0 to 1000000.Would you like more information about Financial Assistance and applying online emailed to you?* Yes No Name* First Last Email* This field is hidden when viewing the formPhone # For Text (Optional)This field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formFamily Additional Total 4720This field is hidden when viewing the formYearly Rate 13590This field is hidden when viewing the formCalculated % FPLThis field is hidden when viewing the formAnnual Income
