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Financial Assistance Application

Please complete all areas of the application form. If any area does not apply to you, write N/A or "0" in the space provided.

Please note, the financial assistance policy does not apply to:

a. Future services are not accepted; services must be rendered before application can be processed

b. Out of county residents are eligible for emergency cases only

c. Kaweah Health Medical Group, Sequoia Health and Wellness Clinic, and Separately billable physician services such as a primary care physician or California Emergency Physicians (Emergency Room Physicians) are not applicable.