Financial Assistance Application
How to Complete a Financial Assistance Application
· Please print the patients name in the location Patients Name
· If you know the patients CPI please enter is in location CPI#
· Please enter the date the application is being completed in the date location
· If the patient is a minor (under 18 years of age) please print the responsible party that is completing the application on their behalf in the Name of Applicant Location
· If the patient is a minor (under 18 years of age) please list the relationship to the patient of the responsible party completing the application in the Relationship to Patient Location
· Please enter the patients current address in the Address location
· Please enter a valid phone number for the patient in the Telephone location
· Place a check mark in the location beside Are you a US Citizen, if you are a US Citizen if not leave this space blank
· Please place a check mark in the field next to Are you a SC/GA Resident if you are a resident of the given state on your application, if not please leave this field blank
· Please place a number in the blank beside the Total Household Size
· Please place a number in the blank beside Total # of Dependents, this should reflect the total number of children living in the household that the patient/applicant is responsible for
· In the boxed section please list fill out a line to include Name, Birthdate, Relationship to the patient, and gross income for that person listing the income to be either weekly, monthly or yearly
· Each column should be completed for the total number of people listed in the household
· This information should correlate with the Total Household Size listed on the application
· Please print your name validating that the information provided is correct, date and sign
· The bottom line will be completed by hospital staff
· In order to completed your application acceptable income verification will need to be provided
· If you have no income, a denial of Medicaid eligibility is required.
Send documentation to:
Patient Accounting Department
1120 15 St., HS 1331
Augusta GA 30912.
No individual within the program will be charged more than the amounts generally billed for emergency or other medically necessary care.
For more information, call 706-721-2961