Financial Assistance Application

Below is an application for the UAMS Health Financial Assistance Program.  This program is available to Arkansas residents (and Texarkana, TX residents) who meet certain income requirements.  To apply for this program, please complete the enclosed application and provide the following documentation:

• Proof of income from all sources for all adult members in your household for the past 2 months, including either pay stubs or verification of self-employment income.
• Proof of Arkansas residency.
• Medicaid approval letter, denial letter or the validation ID from the Medicaid application.  You must apply for Arkansas Medicaid and provide Medicaid’s response to your Medicaid application.  Below is the website to apply for Medicaid.

If you have any questions about the application or need help completing the application, you can contact us at one of the telephone numbers below. We will notify you when the application is received by our office.  You will also receive notification indicating approval or denial of financial assistance within 30 days of receipt.

If the application packet is not complete, we will notify you in writing of the items missing.  You will have 15 days to provide the necessary information.  Failure to provide the required information may result in a denial for financial assistance.

If any of the provided information is found to be false or untrue, the application will be denied and any discount received will be withdrawn.  The application will also be denied if you fail to cooperate with the Medicaid application process.

The application can be mailed to the address at the top of this letter, emailed to OFCFinancialCounseling@ uams.edu or delivered to our office or any UAMS Health clinic. The date the application is returned will be used to determine the effective date of the discount if assistance is approved.

Contact Us

Office of Financial Clearance
UAMS Health
501-686-7400 (local)
855-841-8307 (toll-free)