UCI Health will see you now: Welcome to our new co-workers and patients from Fountain Valley, Lakewood, Los Alamitos and Placentia Linda! 

Charity Cover Letter - English

Thank you for choosing UCI Health for your healthcare needs.

Please complete and return the financial assistance screening form to begin the process of applying for Financial Assistance. The screening form must be fully completed. Please return the completed form with the listed documentation below as soon as possible so that we may respond to your request for assistance.

Please include the following with your screening form:

  • Copy of two most recent pay stubs, or individual tax return, including W-2 and 1099 forms
  • Copy of two most recent bank statements

Missing documentation may delay the processing of your application and could result in a denial for financial assistance. If you are missing any of the above documentation, please explain why this information is not available.

If you have any questions, please feel free to contact our Shared Business Office at (833) 353-7700, Monday thru Friday from 8:30 a.m. to 4 p.m.

Apply for Assistance


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