The Wellstar financial assistance application is a short form, backed by income and asset documentation, that asks Wellstar Health System to reduce or eliminate your hospital charges based on household income and family size. You can file it before or after treatment, and you have up to 240 days from the date of your first post-discharge billing statement to submit it. Both insured and uninsured patients are eligible to apply. Once Wellstar has your complete packet, processing takes up to 30 days.
Who Qualifies and for How Much
Wellstar measures eligibility against the Federal Poverty Guidelines (FPG) and sorts approved applicants into four tiers:
- At or below 125% FPG: you pay nothing. Wellstar covers 100% of eligible hospital charges as indigent care.
- 126% to 200% FPG: charity care discounts of up to 97% of the Amounts Generally Billed (AGB), a federal benchmark tied to what insurers actually pay for the same services.
- 201% to 250% FPG (Category 3): you owe 10% of AGB, if you also pass the assets test.
- 251% to 300% FPG (Category 4): you owe 20% of AGB, again subject to the assets test.
The 2025 FPG baseline is $15,650 for one person and $32,150 for a family of four, with $5,500 added per additional household member. A family of four earning under $96,450 falls within the program’s outer edge.1U.S. Department of Health and Human Services. 2025 Poverty Guidelines
The Assets Test for Categories 3 and 4
If your income puts you in Category 3 or 4, your qualifying assets cannot exceed 200% of the total billed charges for the services you received. Qualifying assets include cash, stocks, bonds, savings accounts, and money market funds. Retirement accounts (IRAs, 401(k)s, 403(b) plans), your primary residence, and your main vehicle are excluded. Secondary homes, extra cars, and recreational vehicles may count against you.2Wellstar. Financial Assistance Program Policy
If Your Income Is Above the Guidelines
Patients whose income technically exceeds the tiers can still qualify through what Wellstar calls medical indigency, evaluated case by case when medical costs have drained household resources.3Wellstar Health System. Financial Assistance Program Policy Summary Certain situations can trigger approval without a full income review: a deceased patient with no estate, verified homelessness, or a catastrophic medical event.4Wellstar. Financial Assistance Program Policy
What the Program Covers
The assistance applies to hospital and facility charges for emergency and medically necessary care. It does not cover bills from physicians, even those who treated you inside a Wellstar hospital. Independent specialists, anesthesiologists, and emergency physicians who are not Wellstar employees bill separately, and their charges fall outside this program.2Wellstar. Financial Assistance Program Policy Georgia law does require those non-employed emergency and hospital-based physicians to offer their own discounts to uninsured patients or to patients with high medical costs earning at or below 300% FPG, but you’ll need to contact each provider directly.
So expect more than one bill after a hospital stay. The Wellstar application handles the facility portion. For any physician-group bill, ask that group about its own discount program.
Documents to Gather Before You Start
The form is short. The paperwork behind it is where the work happens. Assembling everything up front prevents the back-and-forth that delays a decision.
Income Verification
- Your most recent IRS Form 1040, plus W-2 or 1099 forms from the same tax year.
- Three months of recent pay stubs, or a letter from your employer confirming gross wages.
- Two months of written statements for other income sources: unemployment compensation, disability, retirement distributions, Social Security, student loan refunds, alimony, child support, or TANF activity.
- A current profit-and-loss statement if you are self-employed.
If You Are Unemployed
- Out of work less than three months: a separation notice from your previous employer.
- Out of work more than three months: a wage inquiry from your state Department of Labor.
- Denied benefits: your unemployment compensation denial letter.
Assets and Outside Support
- Two months of statements for every checking, savings, money market, and investment account in the household.
- Property tax statements, certificates of deposit, and investment account statements showing current values.
- A written statement from anyone outside the household who contributes income or in-kind support to you.
The application lists these requirements at the bottom, so it doubles as a checklist.5Wellstar Health System. Hospital Financial Assistance Program Application
Filling Out the Form
The application runs about two pages. Work through it in order.
Start with patient information: full name, Social Security number, date of birth, Medical Record Number (MRN), and the Wellstar facility where you received care. The MRN appears on your billing statement and links your request to the correct account. A wrong MRN is one of the fastest ways to stall the review.
If someone other than the patient is responsible for the bill, complete the guarantor section with that person’s name, relationship, Social Security number, address, and phone.
For employment, you and your spouse each list employer, position, hourly rate, and whether you work full-time, part-time, or are unemployed. There is room for two employers per person.
List every legal dependent by name, date of birth, and relationship. Answer both yes-or-no questions: whether you have applied for Medicaid, and whether you qualify for COBRA. Answer even when the answer is no. Blank fields raise flags during review.
In the assets section, enter current balances by account type (checking, savings, money market) with the bank name, then monthly amounts for Social Security, pension, alimony, child support, CDs, and other assets. The form also asks about student loan refunds, bankruptcy in the past three years, and any rental property (with monthly income and estimated value).5Wellstar Health System. Hospital Financial Assistance Program Application
Sign and date the bottom. Unsigned applications are treated as incomplete.
How to Submit
Wellstar accepts completed applications several ways. The processing timeline is the same regardless of how it arrives.
- MyChart: log in, complete the application, and upload scanned documents. Fastest, because everything is received immediately.
- Fax: (770) 792-1737.
- Mail: Financial Assistance Program, P.O. Box 748733, Atlanta, GA 30374.
- Phone: 470-245-9998, then select the Financial Assistance option. You can also request a paper application by mail.
- In person: any Wellstar facility registration desk.
The application and the policy summary are available at wellstar.org/for-patients/financial-assistance.6Wellstar Health System. Applying for Financial Assistance
Deadlines to Watch
Two deadlines govern the process. The completed application must be submitted within 240 days from your first post-discharge billing statement. And once Wellstar requests any additional records from you, those records must arrive within 30 days or the application may be closed.5Wellstar Health System. Hospital Financial Assistance Program Application You can also apply before you receive a bill, so there is no reason to wait if you already know you will need help.
After You Submit
Review takes up to 30 days from the date Wellstar has your complete packet. If anything is missing, the clock does not start until the last piece arrives, which is why a thorough first submission beats a fast one.6Wellstar Health System. Applying for Financial Assistance
Your notification will identify the tier you fell into and the percentage of the bill Wellstar will cover. If you are approved for partial assistance, the remaining balance reflects your share under the AGB formula for your tier.
If Your Application Is Denied
Send a written request for reconsideration to the Wellstar Single Business Office, Attn: Vice President, Revenue Cycle, 805 Sandy Plains Road, Marietta, GA 30066. If that decision is still unfavorable, the final level of appeal goes to Wellstar’s Chief Financial Officer.4Wellstar. Financial Assistance Program Policy Explain why you disagree, and attach any new documentation that shows a change in circumstances: a recent job loss, a new medical diagnosis, updated bank statements.
Billing Protections While Your Application Is Pending
Federal tax law puts a buffer between your hospital bill and aggressive collections. Under Section 501(r)(6) of the Internal Revenue Code, a tax-exempt hospital like Wellstar cannot take extraordinary collection actions (ECAs) against you for at least 120 days after sending your first post-discharge billing statement. ECAs include reporting the debt to credit bureaus, placing a lien on your property, garnishing wages, seizing bank accounts, or filing a lawsuit.7Internal Revenue Service. Billing and Collections – Section 501(r)(6)
Before starting any of those actions, Wellstar must send a written notice identifying the specific collection steps it plans to take, along with a plain-language summary of the financial assistance policy. You then get at least 30 days from that notice to submit an application. If you file at any point within 240 days of your first billing statement, all extraordinary collection actions must stop while Wellstar processes it.8eCFR. 26 CFR 1.501(r)-6 – Billing and Collection
So even if collection notices are piling up, submitting the application freezes the process. Don’t ignore the bill, and don’t assume a collections warning means it is too late to apply.