Financial Assistance

Financial assistance provided by Nebraska Medicine is based upon the U.S. Department of Health and Human Services Income Guidelines. Patients must demonstrate an inability to pay for non-elective, medically necessary services in order to qualify for the program. 

To receive assistance, you must provide:

  • Federal Tax Return for the most recent year
  • Company Pay Stubs
  • Proof of all sources of income

Mail the completed application and documents to:

Nebraska Medicine
Attn: Patient Access - Financial Counseling
987530 Nebraska Medical Center
Omaha, NE 68198-7530

Several questions on the application form will help identify if you are eligible for other financial resources such as Medicaid.  If you meet the guidelines for these additional resources, you will be required to apply for assistance through the corresponding organization.

Should you have any questions about this form or the financial assistance requirements, please contact one of our patient financial counselors at 402.559.5346.
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