Uncompensated Financial Aid Program
IMPORTANT NOTE: Financial aid services are only available at Allied Rehab and Heinz Rehab Inpatient and Outpatient facilities, and at Allied Home Health.
Provided below is an application for assistance with medical expenses through Allied Services Uncompensated Financial Aid Program. This program applies to all medically necessary charges incurred at any Allied Services Facility.
Please note that this is only for facility charges and only those professional fees that appear on Allied Services bill. Arrangements for other fees cannot be made by this Health System and must be discussed with the individual practice plan.
Additional instructions are included in the application provided below.
You must include the following with your completed application:
- Your most recent federal income tax return, if you filed one, as well as the federal income tax return of anyone you claim as a dependent, or anyone that claimed you as a dependent.
- Other documents may include: W-2’s social security 1099’s, social security Award Letters, and/or pay stubs for the alst 3 months. What you send will vary depending on the types of income your family had.
- If you feel you may not qualify but the documentation does not fully explain your special circumstances you may include a letter with an explanation. Additional credit may be granted according to your circumstances.
- In any case, be as thorough as you can. Before sending in your documents with you application, please review all your papers yourself to ensure that enough information is available to figure out your gross family income for the past 3 months (or 12 months). Remember, if your family income can’t be determined with the provided documents, we must deny your application.
Additional submission instructions are provided in the application.
Once all your documents are in order, mail your completed application and all associated documents to:
Patient Accounts Department
100 Executive Park
Clarks Summit, PA 18411
For additional assistance with your application process, please contact: