Welcome To Elbert Memorial Hospital

Elbert Memorial Hospital

Financial Assistance Policy and Application

Financial Assistance Application

Elbert Memorial Hospital

Patient Financial Services

Policy Title: Financial Assistance Policy

Effective Date: 12/5/12, Revised 8/1/17; Updated August 2019   

Prepared by: Jeraud Hammond, FHFMA

Updated by: Kathy Whitmire, Revenue Integrity Officer

Purpose: As a part of Elbert Memorial Hospital’s mission to provide comprehensive, coordinated heath care to our patients, we offer several financial assistance programs to help patients with their health care costs for emergent services. All patients are treated with dignity regardless of their ability to pay.

This policy is intended to comply with Section 501 (r) of the Internal Revenue Code. To provide guidelines for uncompensated care provided to persons having a maximum allowable income level of an amount equal to or less than 125% of the Federal Poverty Guidelines and for whom full payment is not received. It excludes amounts classified by the hospital as other free care, bad debt, or contractual adjustments from third-party programs and self-pay discounts. To provide a sliding scale of payment for those persons whose incomes range between 125% and 200% of the Federal Poverty Guidelines.


Policy: POLICY:

  1. All uninsured and underinsured patients can qualify for financial assistance if income guidelines are met. Income less than 125% of FPG will be classified as indigent charity and 100% of bill is covered. A sliding scale for those over 100% is established as follows: 150% FPG – 80% covered, 175% FPG – 60% covered, 185% FPG – 40% covered, and 200% FPG – 20% covered.
  2. Financial Assistance application and guidelines will be used to determine if collection efforts should be stopped and unpaid amounts cost reported. Same guidelines as for the uninsured except an asset test will be applied.




  1. Amount Generally Billed (AGB): The average amount billed to Elbert Memorial Hospital’s insurance companies, Medicare and Medicaid for billable services provided to patients.
  2. Bad debt: Accounts that have been categorized as uncollectible because the patient has been unable to resolve the outstanding medical debt.
  3. Elective: Those service that, in the opinion of a physician, are not medically needed or can be safely postponed.
  4. Household Financial Income: As measured against Federal Poverty Guidelines includes, but is not limited to:
    1. Annual household, pre-tax job earnings
    2. Unemployment compensation
    3. Workers’ Compensation
    4. Social Security & Supplemental Security Income
    5. Veteran’s Payments
    6. Pension or Retirement income
    7. Other applicable income sources, to include, but not limited to: alimony, child support, and any other miscellaneous income source.
  5. ICTF: Indigent Care Trust Fund through the Georgia Department of Community Health which allows some patients to receive healthcare from participating hospitals
  6. Medically Necessary: Hospital services provided to a patient in order to diagnose, alleviate, correct, cure or prevent the onset of worsening of conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or aggravate a handicap, or result in overall illness or infirmity.




This Policy identifies those circumstances when EMH may provide care without charge or at a discount based on a patient’s financial need. Proof of residency is required for qualification into any of the following programs:


  • Presumptive Charity Care- Hospital bill is reduced by 100% on an episode basis for uninsured patients only, who are presumed eligible and not required to complete an application because the patient is receiving benefits from one of the following programs:
    • Food stamps
    • County & State relief programs: Some state counties offer a financial assistance program to designed to provide emergency short-term assistance to persons lacking the resources to meet their basic need for food, shelter, fuel, utilities, clothing, medical, dental, hospital care and burial. WIC Nutrition assistance is also an accepted program.
    • Homelessness
    • Deceased patients with no estate
    • Mentally incapacitated with no one to act on the patient’s behalf


EMH will apply the stated presumptive eligibility criteria to uninsured patients as soon as possible after they receive health care services from EMH.


  • Financial Assistance – Charity Care- Hospital bill is reduced on a sliding scale from 20-100% based off of the Federal Poverty Guidelines, subject to submission of all required documentation (see below section on required documentation). Charity Care may be applied after primary insurance payment to cover deductibles, coinsurances, and copays.
    • Family income is equal to or less than 200% of the Federal Poverty Guidelines
    • Procedure/Requirements: The hospital Patient Registration personnel should attempt to identify potential uncompensated care upon admission or outpatient registration. The Patient or Patient Representative can fill the application out and return the application within 30 days of the first post-discharge bill also the application may be done in writing or orally by the Financial Counselor.
    • With the patient’s permission, the Financial Counselor may ask for submission of the most recent Federal Income Tax Return in determining income or may assist the patient in filing for Medicaid. After determination of classification of eligibility, the patient should be notified with the appropriate form. (Attached are forms for each specific eligibility or ineligibility).
    • A patient’s medical needs will receive first priority in all cases, and only after needs have been determined will the patient’s ability to pay be determined.
    • Out of County residents will not be considered for Charity Care, only Elbert County residents are eligible.
    • Applications can be accessed on the hospital website, by email request, at each Registration area and by mail at no charge.
    • Each Registration area must have a notice posted regarding the offering of Charity and Financial Assistance. Statements also must offer the availability of both
    • Doctors, Labs and Radiology Facilities that are used within the hospital are notified of our charity approval for each patient. Each contracted Facility/Doctor uses their own guidelines for approving Charity and will bill separately for their services provided.

Contact Information for contracted physicians:

  • Southland MD 1-844.251.3342
  • Radiology South Georgia Radiology Associates – 888-760-2455
  • Pathology – LabCorps – 800-845-6167
    • Approval is good for 1 year from the date of the approval.


  • Required Documents
    • Pay Stubs
    • Employee W-2 Forms
    • Federal income tax return
    • Statements from employer
    • Social Security Award Letter, benefit payment check
    • Unemployment compensation letter
    • Bank Statements
    • Housing/Utility Assistance, Food Stamps, Alimony









For purposes of this policy, “charity” or “financial assistance” refers to healthcare services provided by EMH without charge or at a discount to qualifying patients. The following healthcare services are eligible for charity:


  • Emergency medical services provided in an emergency room setting;
  • Services for a condition which, if not promptly treated, would lead to an adverse change in the health status of an individual;
  • Non-elective services provided in response to life-threatening circumstances in a non-emergency room setting; and Medically necessary services, evaluated on a case-by-case at EMH’s discretion




EMH has the right to pursue collections directly or working with a third-party collection agency. If the Financial Assistance Application Form is not completed by the specified deadline, EMH will pursue collections from the patient. EMH may list a patient’s account with a credit agency or credit bureau. EMH reserves the right to attach liens to insurance (auto, liability, life and health) in connection with its collections process to the extent a third party liability insurance exists. No other personal judgements or liens will be filed against FAP-eligible individuals. No collection action will be initiated until at least 120 days after EMH provides its first post-discharge billing statement.



Elbert Memorial Hospital will never bill any financial-assistance-eligible individual more than the average amount generally billed to someone who is insured. AGB is determined using a ‘look back’ method, where past claims for all commercial and governmental payors are reviewed to compute the average discount.



EMH respects the confidentiality and dignity of its patients and understands that the need apply for financial assistance may be a sensitive issue. EMH staff will provide access to financial assistance related information only to those directly involved with the determination process and will comply with all HIPPA requirements for handling personal health information.



To download a copy of the financial assistance application, please click HERE.

Paper copies of the application are also available in the following locations:

  • Emergency Department
  • Outpatient Registration
  • Patient Financial Services

Completed Applications should be returned or mailed to:

Elbert Memorial Hospital

4 Medical Drive

Elberton, Ga. 30635

Or email us at dardister@emhcare.net


For Questions related to the application or for billing questions please call: