Application for Financial Assistance

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

Below is an application for Financial Assistance for services rendered at Fulton County Health Center. Separate billings may be incurred by the following providers which are excluded from the Fulton County Health Center Financial Assistance program: FCHC Medical Group, Pathology (APS), Radiology (APEX), Emergency Room Physicians (Riverwood), and Anesthesia (NAP).

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
  • 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
  • Do you have an HSA/FSA account?  You must provide the most recent statement showing the available balance

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

  • Applied for Medicaid
  • Copies of current income and previous year taxes
  • Attach current copies of all medical bills (Medical, Prescriptions, Dental and Vision)
  • Debt to Income
Family Size HCAP Charity
1 14,580 29,160
2 19,720 39,440
3 24,860 49,720
4 30,000 60,000
5 35,140 70,280
6 40,280 80,560
7 45,420 90,840
8 50,560 101,120

DOS 1/17/2023 – 1/16/2024
Add $5,140 for each additional person
if the family unit has more than eight members.

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 1/17/2024 – Present
Add $5,480 for each additional person
if the family unit has more than eight members.

Fill out my online form.