Wellstar Financial Assistance Application PDF Details

Financing health care can be difficult, especially if you are uninsured or have a high-deductible health plan. Wellstar Financial Assistance Application Form can help you pay for the care you need. This form is designed to help patients who cannot afford to pay for their health care services receive discounts on their medical bills. You may qualify for assistance if your income falls below a certain level or if you have large out-of-pocket expenses. Learn more about eligibility requirements and how to apply for financial assistance from Wellstar.

If you wish to first understand how much time you will need to fill in the wellstar financial assistance application and what number of pages it's got, here's some basic data that might be helpful.

QuestionAnswer
Form NameWellstar Financial Assistance Application
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameswellstar assistance application, financialassistantapplications wellstar org, welstar, wellstar financial assistance application

Form Preview Example

WellStar Health System

Financial Assistance Application

P.O Box 670747

Marietta, Georgia 30066

Phone: 770-792-1791

PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Resident

 

 

 

 

Yes

 

 

 

No

Account Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Corporate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

SS#:

 

 

 

 

 

Birthdate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GUARANTOR and SPOUSE INFORMATION

 

Married

 

Divorced

 

 

 

Separated

 

 

Widow

Name:

 

 

 

 

 

 

 

 

 

SS#

 

 

 

 

 

Relationship to Patient:

 

 

 

 

Birthdate:

 

/

 

/

Home Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #: (

)

 

 

 

 

Other Phone: (

)

 

 

 

 

 

 

 

 

 

 

 

 

Employer:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Annual or

 

 

 

Working Full or Part-time

Work #:

 

 

 

 

 

 

Position:

 

 

 

 

 

Hourly Pay:

 

 

 

 

 

(circle one)

Spouse’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

SS#

 

 

 

 

 

Birthdate:

 

/

/

 

 

 

Employer:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Annual or

 

 

 

Working Full or Part-time

Work #:

 

 

 

 

 

 

Position:

 

 

 

 

 

Hourly Pay:

 

 

 

 

 

(circle one)

 

 

 

 

 

 

 

Legal Dependents

(List only those dependents that can be claimed on your federal tax form.)

 

 

 

 

 

Name (First, Middle, Last)

Birthdate (mm/dd/yyy)

Relationship

/ /

/ /

/ /

/ /

/ /

/ /

/ /

Have you applied for Medicaid?

Yes No

Do you qualify for Cobra?

Yes No

Assets and Other Income Sources

Checking

 

Balance

$

Monthly Pension $

 

 

 

 

Savings

 

 

Name of Bank:

 

Balance

$

 

 

 

 

 

 

 

 

 

 

Social Security:

$

 

IRA

 

$

 

Name of Bank:

CD’s $

Food Stamps $

 

 

Landowner:

Yes or No (Circle one)

If yes, how

 

401K

$

many acres?

 

 

 

 

 

Do you own

Yes or No (Circle one)

If yes, what is the

 

 

 

 

 

 

rental property?

monthly income:

 

$

 

 

 

Have you filed for bankruptcy in the past 3 years?

(Circle one)

 

 

 

 

Yes or No

 

If yes, provide the date:

 

 

 

 

 

 

Value

 

$

 

 

What is the

 

 

 

 

 

 

property value?

$

/

 

/

 

 

Do you own stocks or bonds? Yes or No (Circle one)

If yes, what is the value?

$

WellStar Health System is committed to providing financial assistance to patients who have sought medically necessary care at WellStar Health System but have limited or no means to pay for that care. WellStar Health will provide emergency medical care to all individuals, regardless of their ability to pay or eligibility under the Community Financial Assistance Policy.

In order to qualify for financial assistance, cooperation with WellStar Health is necessary in identifying and determining alternative sources of payment or coverage from public and private payment programs. In order to qualify for financial assistance, the following is necessary:

Required information:

Submit a true, accurate, signed and completed application for financial assistance; and

Provide a copy of the prior year Federal Income Tax Return and W2/1099 (including all schedules)

Provide two of the following if unable to provide a copy of the most recent Federal Income Tax Return:

Provide 3 months of the most recent pay stubs (or certification of unemployment); or

Separation Notice or unemployment claim if unemployed; or

Provide 3 current bank statements for all checking and savings accounts; or

Provide award letter from Social Security Office; or

Provide Current Profit and Loss report for all self-employed applicants; or

Current CD, 401k, 403b, IRA and other investment statements; or

Provide Asset Statement, with equity adjustments (Rental property, land, second houses)

This information must be received in order to process your application. If you fail to be compliant in returning the above information within 10 business days, WellStar Health System will not process your account for Community Financial Assistance approval. You may contact 678-838-5750 with questions.

Comments:

I hereby request that WellStar determine my eligibility for Community Financial Assistance. I understand that the information which I submit regarding my annual income and family size must be verified. I also understand that if the information I submit is determined to be false, such a determination will result in a denial of eligibility for Community Financial Assistance. I further agree to make application for any assistance (i.e., Medicaid, Medicare, State Aid (for cancer), Vocational Rehab, Insurance, etc.) that may be available for payment of my WellStar account charges. I will fully cooperate in taking whatever actions may be deemed necessary to obtain such assistance, and will assign or pay WellStar the amount recovered for WellStar charges. I agree to pay any balances remaining after the Community Financial Assistance adjustment is made. Failure to do so will result in a reversal of any Community Financial Assistance write-offs.

I affirm that the above information is true and correct to the best of my knowledge.

 

 

 

Guarantor Signature:

Date:

 

 

Co-Guarantor Signature:

Date:

 

 

 

 

 

Watch Wellstar Financial Assistance Application Video Instruction

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