Financial Assistance at NHCH

Please visit Patient Financial Services where a representative will provide you with an application for Financial Assistance upon request. You may also contact a Patient Account Representative at 808-881-4610, Monday – Friday, 8:00 am – 4:00 pm to request an application.

• Financial Assistance Application
• Income Asset Qualifiers and Discount Rates

List of Covered Providers

• View Here

Availability of Translations

Financial Assistance Application and Plain Language Summary are available in Japanese, Samoan, Vietnamese, Korean, Chinese, Tongan, Chuukese, Tagalog and Ilokano.  

Japanese:
慈善医療ポリシーPlain Language Summary（概要説明書) – 付属書D 
クイーンズ・ヘルスシステム システムワイド管理ポリシー＆手順 
資金助成申請書 

Samoan
Aiaiga mo Fesoasoani Maua Fua Aotelega o Gagana – Exhibit D
Polokalame fa’a le ‘au’aunaga mo le lautele ma fa’atinoga mole’āu’aunaga fa’a le falema’i.
Talosaga mo Fesoasoani Tau Tupe. 

Vietnamese:
Chính Sách Chăm Sóc Từ Thiện Tóm Tắt Bằng Ngôn Ngữ Đơn Giản – Phụ Lục D 
Chính Sách và Thủ Tục Hành Chính Toàn Hệ Thống của Hệ Thống Y Tế The Queen 
Đơn Xin Hỗ Trợ Tài Chính 

Korean:
자선 진료 정책 쉬운 언어 요약본 – Exhibit D 
Queen’s Health System의 시스템 전반의 행정 정책 및 절차 
재정 지원 신청서 

Chinese:
慈善医疗政策简明语言摘要 – 附件D 
皇后健康系统的全系统范围的管理政策和程序
经济援助申请 

Tongan:
Polisī ki he Tokoni ‘Ofá Fakamatala nounou ‘i he Lea Mahino – Fakamatala D 
Ngaahi Polisī mo e Founga Ngāue Fakakātoa ‘a e Queen’s Health System
Kole Tokoni Fakapa’anga

Chuukese:
Charity Care Policy Mesenapen Poraus Non Foosun Fonuom (“Plain Language Summary”) – Taropwe D 

Annuk me Otoot fan “System-Wide” non tettenin ewe Queen’s Health System

Application ren Aninisin Monien Niwinum non Pioing (“Financial Assistance Application”) 

Tagalog:
Patakaran sa Kawang-gawang Pangangalaga Buod sa Simpleng Lengguwahe – Exhibit D 
Mga Pambuong Sistemang Administratibong Patakaran at Proseso ng The Queen’s Health System 
Aplikasyon para sa Pinansiyal na Tulong 

Ilokano:
Pagannurotan iti Tulong a Pannaripato Pakabuklan iti Simple a Pagsasao – Exhibit D 
Administratibo a Pagannurotan ken Wagwagas iti Intero a Sistema ti The Queen’s Health System 
Aplikasion para iti Pinansial a Tulong 

Please return your completed application to Attention: Business Services at

The Queen’s Medical Center Punchbowl, 1301 Punchbowl Street, Honolulu, Hawaii 96813

The Queen’s Medical Center West Oahu, 91-2141 Fort Weaver Road, Ewa Beach, Hawaii 96706

Molokai General Hospital, 280 Home Olu Place, Kaunakakai, Hawaii 96748

North Hawaii Community Hospital, 67-1125 Mamalahoa Highway, Waimea, Hawaii 96743