CommonSpirit Health – Appeal

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

List of CommonSpirit Health location(s) where patient was treated.*

Patient Name*

First Middle Last

Patient Date of Birth*

Is the Patient the person responsible for paying for care?*

Yes

Person Responsible for Paying Bill (if not the patient)*

First Last

Person Responsible for Paying Bill Date of Birth*

Address*

Street Address City State Zip

Phone Number

Patient Account Number(s)*

Date of Determination Letter

Reason for the Denial

Please provide why you believe your initial financial assistance determination was incorrect.

Document Upload

Please upload documents such as pay stubs, bank statements, tax returns, and other income statements to support your appeal.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 30 MB, Max. files: 5.

Please do not close your browser or leave this page until you see the confirmation page.