Online Application "*" indicates required fields Welcome to Augusta Health’s online financial assistance application! In order to process an application, we need supporting documents to verify the household’s financial situation. Required documents include all of the following that apply to the household: Proof of gross income for the last three months: for you and/or your spouse (all paystubs/income statements, Social Security/Disability Letter, Pension Statement, etc.). If you and/or your spouse are unemployed, you must provide documentation showing how you support yourself and your family. All bank statements for the last three months: for you and/or your spouse. The bank statement(s) must show the bank name, account number, account holder’s name and address, contain all pages, and show all transactions. Legal Custody Documentation: Please provide legal documentation for all children who are in your physical custody by court order.After reviewing the submitted application, we may reach out to assist with additional programs and insurance options available. Please have an electronic copy or pictures of the required documents ready before starting the application. Financial applications without documentation will not be processed.Do you have your proof of income documents and bank statements ready?* Yes No I will mail in or drop off my proof of income documents and bank statements to Augusta Health in the next 10 days.If documents are not received the financial application will not be processed. Yes Applicant's Name* First Middle Last Applicant's Date of Birth*Applicant's Social Security Number – if applicableApplicant's ITIN – if applicableApplicant's Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address the same as your physical address? Yes No Applicant's Mailing Address Mailing Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Applicant's Phone Number*Marital Status* Single Married Widowed Divorced Separated Separated SinceSpouse's Name* First Middle Last Spouse's Date of Birth*Spouse's Social Security Number – if applicableSpouse's ITIN – if applicable How many children UNDER THE AGE OF 18 are in the home?*This includes your own children and any in your legal custody by court order.Please enter a number from 0 to 7.Child 1 – Name* First Last Child 1 – Date of Birth*Child 1 – Social Security NumberChild 1 – Relationship to Applicant*Child 2 – Name* First Last Child 2 – Date of Birth*Child 2 – Social Security NumberChild 2 – Relationship to Applicant*Child 3 – Name* First Last Child 3 – Date of Birth*Child 3 – Social Security NumberChild 3 – Relationship to Applicant*Child 4 – Name* First Last Child 4 – Date of Birth*Child 4 – Social Security NumberChild 4 – Relationship to Applicant*Child 5 – Name* First Last Child 5 – Date of Birth*Child 5 – Social Security NumberChild 5 – Relationship to Applicant*Child 6 – Name* First Last Child 6 – Date of Birth*Child 6 – Social Security NumberChild 6 – Relationship to Applicant*Child 7 – Name* First Last Child 7 – Date of Birth*Child 7 – Social Security NumberChild 7 – Relationship to Applicant*Are any of the children listed above in your physical custody by court order? Yes No Legal Custody DocumentationPlease provide legal documentation for all children who are in your physical custody by court order. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Employment Status*Check all that apply. Full-time Part-time Full-time Student Self-Employed Retired Unemployed Applicant's Current Full-time Employer's Name*Applicant's Full-time Employer's Phone Number*Applicant's Part-time Employer's Name*Applicant's Part-time Employer's Phone Number*Do you have another part-time employer to add? Yes No Applicant's Second Part-time Employer's Name*Applicant's Second Part-time Employer's Phone Number*Do you have another part-time employer to add? Yes No Applicant's Third Part-time Employer's Name*Applicant's Third Part-time Employer's Phone Number*Unemployed Since*Applicant's Source(s) of Income*Please check all that apply. Employment Self-Employment Social Security/Disability Retirement Pension Employer Short or Long Term Disability Alimony Child Support Unemployment Benefit Other No Income Spouse's Employment Status*Check all that apply. Full-time Part-time Full-time Student Self-Employed Retired Unemployed Spouse's Current Full-time Employer's Name*Spouse's Full-time Employer's Phone Number*Spouse's Part-time Employer's Name*Spouse's Part-time Employer's Phone Number*Do you have another part-time employer to add? Yes No Spouse's Second Part-time Employer's Name*Spouse's Second Part-time Employer's Phone Number*Do you have another part-time employer to add? Yes No Spouse's Third Part-time Employer's Name*Spouse's Third Part-time Employer's Phone Number*Unemployed Since*Spouse's Source(s) of Income*Please check all that apply. Employment Self-Employment Social Security/Disability Retirement Pension Employer Short or Long Term Disability Alimony Child Support Unemployment Benefit Other No Income Please provide the following information for the sources that were selected.Applicant's Employment Income Amount*Please provide the total employment income received by the applicant from all sources.How often do you receive employment income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Employment IncomePlease upload copies of all paystubs for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Self-Employment Income Amount*How often do you receive self-employment income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Self-Employment IncomePlease upload a copy of last year’s federal income tax return or an income and expenses report for the most recent three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Social Security/Disability Income Amount*How often do you receive Social Security/Disability income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Social Security/Disability IncomePlease upload a copy of your Social Security/Disability Benefit letter. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Retirement Income Amount*How often do you receive retirement income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Retirement IncomePlease provide copies of your retirement income statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Pension Income Amount*How often do you receive pension income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Pension IncomePlease provide copies of your pension statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Employer Short or Long Term Disability Income*How often do you receive employer short or long term disability income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Employer Short or Long Term Disability IncomePlease provide copies of your employer short or long term disability statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Alimony Amount*How often do you receive alimony payments?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of AlimonyPlease provide copies of your alimony statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Child Support Amount*How often do you receive child support payments?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Child SupportPlease provide copies of your child support statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant’s Unemployment Benefit Amount*How often do you receive unemployment income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Unemployment BenefitsPlease provide copies of your unemployment statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Applicant's Other Income Amount*How often do you receive other income?*WeeklyBi-WeeklyMonthlyBi-MonthlySource of Other Income*Proof of Other IncomePlease provide documentation for all other income received in the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Employment Income Amount*Please provide the total employment income received by the applicant’s spouse. How often does your spouse receive employment income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Employment IncomePlease upload copies of all paystubs for the last three months for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Self-Employment Income*How often does your spouse receive self-employment income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Self-Employment IncomePlease upload a copy of last year’s federal income tax return or an income and expenses report for the most recent three months for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Social Security/Disability Income Amount*How often does your spouse receive Social Security/Disability income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Social Security/Disability IncomePlease upload a copy of the Social Security/Disability Benefit letter for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Retirement Income Amount*How often does your spouse receive retirement income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Retirement IncomePlease provide copies of the retirement income statements for the last three months for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Pension Income Amount*How often does your spouse receive pension income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Pension IncomePlease provide copies of the pension statements for the last three months for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Employer Short or Long Term Disability Income*How often does your spouse receive employer short or long term disability income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Employer Short or Long Term Disability IncomePlease provide copies of your employer short or long term disability statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Alimony Amount*How often does your spouse receive alimony payments?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of AlimonyPlease provide copies of your alimony statements for the last three months. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Child Support Amount*How often does your spouse receive child support payments?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Child SupportPlease provide copies of the child support statements for the last three months for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Unemployment Benefits Amount*How often does your spouse receive unemployment income?*WeeklyBi-WeeklyMonthlyBi-MonthlyProof of Unemployment BenefitsPlease provide copies of the unemployment statements for the last three months for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Spouse's Other Income Amount*How often does your spouse receive other income?*WeeklyBi-WeeklyMonthlyBi-MonthlySource of Other Income*Proof of Other IncomePlease provide documentation for all other income received in the last three months for the applicant’s spouse. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. If you report $0 income, please provide an explanation for how you are being supported.*If you report $0 income, please provide an explanation for how you are being supported.* Do you have any bank accounts?* Yes No Does your spouse have any bank accounts?* Yes No Bank Name*Account Type* Checking Savings Money Market Other Other – What kind of account?*Current Balance*Do you have any other bank accounts?Please provide all household bank accounts. Yes No Bank Name*Account Type* Checking Savings Money Market Other Other – What kind of account?*Current Balance*Do you have any other bank accounts?*Please provide all household bank accounts. Yes No Bank Name*Account Type* Checking Savings Money Market Other Other – What kind of account?*Current Balance*Do you have any other bank accounts?*Please provide all household bank accounts. Yes No Bank Name*Account Type Checking Savings Money Market Other Other – What kind of account?*Current Balance*Do you have any other bank accounts?*Please provide all household bank accounts. Yes No Bank Name*Account Type* Checking Savings Money Market Other Other – What kind of account?*Current Balance*Bank StatementsPlease upload all bank statements for the last three months, for you and/or your spouse, if applicable. The bank statement(s) must show the bank name, account number, account holder’s name and address, contain all pages, and show all transactions. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Please select any that apply to your living situation* Rent / Lot Rent Own – with mortgage Own – mortgage paid in full Own – lifetime rights I live with someone else and don’t pay Name of person providing support* First Last Relationship to applicant*Phone number for person providing support*Monthly mortgage/rent amount:*Do you own a second home? Yes No If yes, monthly rent income:Do you own or lease your vehicle?* Own Lease I do not have a vehicle Monthly car payment amount:Please select the range of your estimated monthly living expenses (excluding housing expenses):* $0 – $1,000 $1,000 – $2,000 Above $2,000 Do you receive SNAP/EBT benefits?* Yes No If yes, please provide the monthly benefit amount:Did you file taxes for the prior year?* Yes No If no, please provide the reason why:* Does your employer offer health insurance?* Yes No Do you have health insurance?* Yes No Applicant's Insurance Company Name*Applicant's Insurance Member ID*Does your spouse's employer offer health insurance?* Yes No Does your spouse have health insurance?* Yes No Spouse's Insurance Company Name*Spouse's Insurance Member ID*Have you recently applied for Medicaid?* Yes No If yes, date of applicationMedicaid Application Status Approved Denied Pending Please check all that apply to you: I am Blind Pregnant Disabled Have End Stage Renal Disease (ESRD) None Of The Above Have you recently applied for disability?* Yes No If yes, date of applicationMedical Insurance and/or Medicaid Card – Front & BackPlease attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. Medicaid Denial LetterPlease attach a copy of the Medicaid Denial letter. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, gif, ico, doc, docx, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 20. This field is hidden when viewing the formTotal Applicant IncomeThis field is hidden when viewing the formTotal Spouse IncomeThis field is hidden when viewing the formTotal Family Income 3 months prior to the date of service?This field is hidden when viewing the formTotal Family Income 12 months prior to the date of service?This field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis field is hidden when viewing the formFamily Additional Total 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsI certify that the above information is true and accurate to the best of my knowledge and that I understand that if any information herein provided is found to be false, this application will be automatically denied. By signing below, I authorize Augusta Health to verify the information provided in this application with the listed employer(s) and any other listed agencies. I understand that I may be asked to provide additional information and documentation to complete my financial assistance application. I also understand that I am fully responsible for any portion of my medical bills not covered through this application.Applicant's Signature*Spouse's Signature* Are You Ready to Submit the Application?* Yes, I’m Ready No Was your experience applying for financial assistance online easy? Yes No Great! Please do not close your browser or leave this page until you see the confirmation page.NameThis field is for validation purposes and should be left unchanged.
