Financial Assistance Application

Augusta University Health offers a financial assistance programs for patients and families experiencing financial difficulty and are unable to pay their hospital bill.  For those who qualify, financial assistance discounts may help with medically necessary services.  Simply complete the Financial Assistance Application, attach copies of documents to verify your income and return via mail.

Please include the following documents with your Financial Assistance Application:

  • Provide a copy of their most recent completed, signed Federal Income Tax 1040A, 1040EZ or 1040 with tax schedules
  • Copy of pay stubs for the most recent past three (3) months with year to date totals for all members of the family working.

If the patient (or responsible party) did not file taxes the last year or if the income situation has changed, the patient should provide photocopies of at least one of the following documents to verify total family gross (before deductions) income.

  • Copy or statement showing alimony, child support, rental income, interest, dividends, regular support payments, income from estates or trusts
  • A dated and signed letter from employer on company letterhead stationary stating the amount of gross income per day period and total number of hours worked per pay period
  • Copy of checks or statement showing pensions, Social Security, Veterans Benefits, Public Assistance. *Temporary Assistance Needy Families (TANF) or Social Security Insurance (SSI) income received by any family members are excluded and will not be included in the calculation of total family gross income.
  • Copy of bank statement showing an “electronic deposit” from the federal government of Social Security, Veterans Benefits
  • Statement showing Worker’s Compensation or Unemployment
  • Copy of Food Stamps Summary
  • Letter from Department of Family and Children Services or Social Security Office verifying income

Please promptly return your income verification documentation in order to complete your financial assistance application. If you do not complete the financial assistance process you will be billed for outstanding hospital balances. 

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

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

Financial Assistance Application

                Financial Assistance Application- English

                Financial Assistance Application– Chinese

                Financial Assistance Application– German

                Financial Assistance Application- Spanish