300 Kingwood Medical Drive Kingwood, Texas 77339

Financial Assistance Program

Memorial Hermann Health System’s Financial Assistance Policy and Admissions Policy govern how financial assistance is provided. On the basis of these policies, a determination will be made regarding a patient’s eligibility for financial assistance.

Payment from all other possible payment sources must be exhausted before a patient can be considered for the financial assistance program. For patients who do not have insurance coverage, alternate funding and payment plan options may be available. Our staff or contracted agents work with patients to identify potential options.

Financial assistance may be available to patients who do not have the means to pay for their healthcare expenses and do not qualify for any government or other programs. A patient may qualify for Financial Assistance based on federal poverty guidelines.

To be considered for this program, patients are required to provide financial information for the household by completing a Financial Information Form along with supporting documentation. To verify income, the most current Federal Income Tax Return should be provided. Other pieces of supporting documentation may be requested in addition to or instead of the Tax Return, including: Last two Employer paycheck stubs, written documentation from income sources, and a copy of all bank statements for the last three months. Memorial Hermann reserves the right to review an applicant’s credit report, property tax records, and/or other public or personal documents prior to a determination regarding program eligibility. Please see policy for specific locations and services covered by our Financial Assistance Policy. Not all locations and services listed on our website are covered by the Financial Assistance Policy.

To request a Financial Information Form, please contact our Customer Service Department at 281-312-4068 or see the forms section below.

Forms - Amharic
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Arabic
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Bengali
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Chinese
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - English
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Farsi
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Formosan
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Mon-Khmer
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Nepali
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Portuguese
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms - Russian
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy