Purpose <p>Financial toxicity is an adverse outcome of cancer care and is often quantified by patient-reported validated survey tools, such as The Comprehensive Score for Financial Toxicity (COST). We aimed to examine the association of objective financial measures of hospital out-of-pocket (OOP) expenses and write-offs with the patient derived COST scores in patients with gynecologic cancer.</p> Methods <p>We identified individuals who completed our cross-sectional survey in discrete periods between 2017 and 2021. Response rates for these periods ranged from 75 to 95%. Hospital financial data was abstracted for respondents, including OOP payments and write-offs in the year before survey completion. Write-offs occurred when patients did not complete payments and included bills forgiven by the hospital or sent to collections. Chi-square, Fisher’s exact, Kruskal–Wallis, and Cochran-Armitage tests were used to compare variables.</p> Results <p>Among 323 respondents, median COST score was 29 (IQR 22–36) and 13% had severe, 25% moderate and 62% mild financial toxicity. Increased financial toxicity was associated with age, race, partner, employment status, insurance type, and income (<i>p</i> &lt; 0.05). Most (63%) respondents had OOP payments and 31% had write-offs. The moderate financial toxicity group had the highest median OOP payment ($799 ($246–$2,004)) as compared to those with severe and mild financial toxicity (<i>p</i> = 0.01). Meanwhile, those with severe financial toxicity were more likely to have a write-off (44%), compared to the moderate and mild financial toxicity groups (<i>p</i> trend = 0.02) and had the highest median write-off amount ($417 ($150–$827), <i>p</i> = 0.03).</p> Conclusion <p>Patient-reported financial toxicity is associated with objective financial measures of hospital out-of-pocket costs and write-offs.</p>