Department of State Hospitals Financial Assistance Program

As required by statute, the Department of State Hospitals (DSH) must collect for cost of care, treatment and maintenance provided to patients during their hospital admission. The 2022 Budget Act, Health Omnibus via Chapter 47, Statutes of 2022 (Senate Bill 184) included statutory changes to provide DSH the authority to develop and implement a Financial Assistance Program. DSH recognizes that medical costs can be burdensome and therefore developed the Financial Assistance Program to assist eligible patients who cannot afford to pay their cost of care balance. Patients who apply for financial assistance and are approved may have their debt to DSH canceled or reduced. Implementing a Financial Assistance Program is permissible under Centers for Medicare and Medicaid Services rules and regulations as well as state law pursuant to Welfare and Institutions Code section 7276(b)(1).

Filing an application

Patients or their representative may submit an application. Applicants can complete the Financial Assistance Program Application by:

  • Downloading the electronic version, filling it out online and saving it to their computer or device.
  • Filling out a paper copy, either by downloading and printing or the copy received at discharge or by mail.

    Download the application
If a patient is unable to complete a printed or electronic application, please contact DSH by phone (916) 654-1501 or email for assistance.

Once completed, the application can be mailed, emailed, or faxed to DSH.

Department of State Hospitals
Attention to: Patient Cost Recovery Section, Trust Office
1215 O Street, MS-3
Sacramento, CA 95814

Fax: (916) 651-8908

For additional information on how to complete the application, access the Financial Assistance Program Application Instructions.

Applying for Financial Assistance

If a patient was admitted to a DSH facility and is liable for their cost of care, the patient can complete an Financial Assistance Program Application to determine if their debt qualifies for cancelation or reduction. Eligible patients may apply after discharge from DSH. Once DSH receives a completed application and supporting documents as listed in the Financial Assistance Program Application Instructions, the patient will receive written confirmation of receipt and the application review process will begin. DSH may request additional documents to help determine debt cancelation or reduction. Examples of additional documentation can be found under the section titled "Documents."


Documentation can include, but are not limited to:
  • Proof of income and assets. This can include a W-2 or document confirming benefits such as Supplemental Security Income (SSI), disability, retirement, etc.
  • Documents showing stocks and bonds.
  • Bills showing monthly living expenses. This can include bills for mortgage or rent.

Forms and Additional Resources

For additional questions, please reach out to DSH Patient Cost Recovery Section (PCRS), Trust Office Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. at the contact below:

Phone: (916) 654-1501