Applications for Financial Assistance

How to complete the Application for Financial Assistance 

  • 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.

If you have any questions, please contact our Customer Service Department at (706) 721-2961.

Send documentation to: 
Patient Accounting Department
1120 15 St., HS 1331
Augusta GA    30912.