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Department of State Hospitals Financial Assistance Program

As required by state and federal law, the Department of State Hospitals (DSH) must collect for cost of care, treatment and maintenance provided to patients during their hospital admission.

DSH recognizes that medical costs can be burdensome and has developed the Financial Assistance Program to assist eligible patients who cannot afford to pay their cost of care balance.

If a patient was admitted to a DSH facility and is liable for their cost of care, the patient can complete an application to determine if their debt qualifies for cancelation or reduction. Eligible patients receive a copy of an application upon discharge. Patients or their representatives may only apply after discharge from DSH.

Download the application

Once DSH receives a completed application and supporting documents, the patient will receive written confirmation of receipt and the application review process will begin. DSH may request additional documents to help determine debt cancelation or reduction.

Patients receiving eligible public benefits with supporting documentation may qualify for full debt relief with a simplified application process. Examples of eligible public benefits can be found in the “Documents” section below.

More Information About the Financial Assistance Program

The 2022 Budget Act, Health Omnibus via Chapter 47, Statutes of 2022 (Senate Bill 184) included statutory changes to provide DSH the authority to develop and implement a Financial Assistance Program. Implementing a Financial Assistance Program is permissible under Centers for Medicare and Medicaid Services rules and regulations, as well as state law pursuant to Welfare and Institutions Code section 7276(b)(1).

For additional information on how to complete the application, please view the Financial Assistance Program Application Instructions. If you are unable to complete a printed or electronic application, please contact DSH by phone (916) 654-1501 or email DSHSacTrustOffice@dsh.ca.gov for assistance.

Completed applications can be mailed, emailed, or faxed to DSH.

Mail:
Department of State Hospitals
Attention to: Patient Cost Recovery Section, Trust Office
1215 O Street, MS-3
Sacramento, CA 95814

Email: DSHSacTrustOffice@dsh.ca.gov
Fax: (916) 651-8908

Documents

Acceptable documents include, but are not limited to:
  • Proof of income and assets. This can include a W-2 or document confirming benefits such as Supplemental Security Income (SSI), disability, retirement, etc.
  • Proof of receipt of public benefits, such as Medi-Cal, Cal Fresh, General Assistance, Supplemental Nutrition Assistance Program (SNAP), CalWorks, etc.
  • Copies of bank statements.
  • Documents showing investments, such as stocks and bonds.
  • Bills showing monthly living expenses. This can include bills for mortgage or rent.

Forms and Additional Resources