Application for Financial Assistance

Thank you for choosing Fulton County Health Center for your healthcare needs.

Enclosed is an application for Financial Assistance for services rendered at Fulton County Health Center. **Other providers who perform services at Fulton County Health Center, but are not covered under this policy include: Pathology, Radiology, Emergency Room Physicians, Anesthesia, and Wound Care.

Your prompt response in completing and returning your financial application will help avoid future billings and/or potential collection activity.

Please call the Financial Counseling Office with any questions, to set up an appointment or for assistance in completing your application. We can be reached Monday – Friday (8am to 4:30pm) by contacting us at 419-330-2669 (option # 2).

Required for Processing:

  • ALL questions must be answered
  • List all family members, ages, and relationship to patient living in household
  • All INCOME lines must be completed (Include 3 and/or 12 months) prior to the date of service
  • Copies of current income and previous year taxes showing adjusted gross income
  • IF ZERO INCOME is reported you MUST include a statement of how you are financially surviving
  • The application must be SIGNED and DATED BY THE PATIENT unless the patient is a dependent/deceased/has a POA

Additional Request: (may be requested for additional financial programs)

  • Applied for Medicaid
  • Attach current copies of all medical bills (Medical, Prescriptions, Dental and Vision)
  • Debt to Income
  • A written Medical and Financial Statement explaining your hardship and why you are requesting
    Financial Assistance
  • Do you have an HSA or FSA account? You must provide the most recent statement showing available balance
Family Size HCAP Charity
1 15,060 30,120
2 20,440 40,880
3 25,820 51,640
4 31,200 62,400
5 36,580 73,160
6 41,960 83,920
7 47,340 94,680
8 52,720 105,440

DOS 01/17/2024 – 01/16/2025
Add $5,380 for each additional person if the family unit has more than eight members

Family Size HCAP Charity 300% FPL 400% FPL
1 15,650 31,300 46,950 62,600
2 21,150 42,300 63,450 84,600
3 26,650 53,300 79,950 106,600
4 32,150 64,300 96,450 128,600
5 37,650 75,300 112,950 150,600
6 43,150 86,300 129,450 172,600
7 48,650 97,300 145,950 194,600
8 54,150 108,300 162,450 216,600

DOS 1/17/2025 – Present
Add $5,500 for each additional person if the family unit has more than eight members.



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