Financial Assistance Application

UK King’s Daughters offers financial assistance to cover the out-of-pocket expenses for qualifying patients. Please complete this application to determine eligibility.

  • For patient billing questions about services from before June 27, 2026: call 606-408-4446 or 877-420-3555

  • For patient billing questions about services after June 27, 2026: call 1-859-205-8875

  • For email: KDFinancialAssistance@uky.edu

Please allow adequate time for the processing of your completed application. After processing is complete you will receive a letter to explain your approval or the reason for denial.

There may be two additional forms to complete, depending on your situation. These forms are to be completed on your behalf. Do not complete them yourself.

  • No Income Verification form: If you and/or your spouse do not have household income, please have whoever is helping you provide your daily needs complete this form for you.

  • Statement of Separation form: If you are separated from your spouse, please have a third party complete this form stating the separation.

Applicant Information

State, Province, or Region
Is the reason for your visit related to an illness, injury, or condition that was caused by the negligence of another person?
Please list any other members of your immediate household (spouse; minor, dependent children; or full-time students over 18 years old)

Source of Household Income – Applicant

Answer the following questions for yourself.
Are you currently working, or have you worked within the past six (6) months?
Are you receiving unemployment or worker’s compensation benefits?
Are you receiving social security, veterans administration, or disability benefits?
Are you receiving a pension or retirement benefits?
Are you receiving alimony, child support, or kinship benefits?
Do you receive rental income?
Do you receive any form of income assistance from the state?

Source of Household Income - Spouse

Answer the following questions for your spouse.
Are you currently working, or have you worked within the past six (6) months?
Are you receiving unemployment or worker’s compensation benefits?
Are you receiving social security, veterans administration, or disability benefits?
Are you receiving a pension or retirement benefits?
Are you receiving alimony, child support, or kinship benefits?
Do you receive rental income?
Do you receive any form of income assistance from the state?

Source of Household Income - Dependents

Answer the following questions for any dependents in your household.
Are you receiving social security, veterans administration, or disability benefits?
Do you receive any form of income assistance from the state?

Resources

Provide the current, estimated value of each of your resources.
$
$
$
$
$
$
How many cars are owned by you, your spouse, and dependents?
Do you own any real estate, not including your current home?

Income Verification Information

  • Pay check stubs for the past three (3) months, or a letter from your employer to verify your gross income
  • Verification of Social Security, Disability, or Worker's Compensation benefits
  • Verification of Unemployment, Retirement, or Pension benefits
  • Verification of Self-employment status and income
  • Verification of Child Support or Alimony payments
  • A copy of ALL forms filed with your Federal Income Taxes for the previous year, including W2's
  • A copy of your bank statements (checking and savings) from the past three (3) months, noting next to each deposit the source of funds for that deposit

Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf jpg jpeg png doc docx.
Do you verify that all of the above answers are complete and accurate to the best of your ability?