Patient Financial Assistance

Below you will find an IHA application for financial assistance. 

IHA Application for Financial Assistance

Please complete the application in full and return to our billing office Attn: Patient Financial Services Manager with the supporting documentation.  Please note that if approved financial assistance eligibility will only be approved for a six month period of time.  If there is any change in your financial status during that six month period of time you are required to notify us as soon as possible about the change. 

Once we receive this completed form we will review to determine your eligibility for financial assistance regarding your outstanding balance with IHA.  You may also include a letter explaining your unique situation.

Send your completed application and supporting documentation to:

IHA Business Services Office-CONFIDENTIAL
Attention: Patient Financial Services Manager
P O Box 0446, Lobby J
Ann Arbor, MI.  48106-0446

Do not hesitate to contact us with any questions you may have.  Our representatives will be happy to assist you. 

Sincerely,

IHA Business Services Office
734.997.7700