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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. Billable physician services such as a primary care physician or California Emergency Physicians (Emergency Room Physicians) are not applicable.