Financial Assistance Program

This program is only available to those who have lived in Columbia County for 12 months and who meet income guidelines.

Eligibility hours: Monday – Friday from 8:30 am to 4:00 pm

Financial assistance program

Offering financial assistance to those who meet eligibility guidelines.

We are committed to excellence in providing quality health care while serving the diverse needs of Columbia County residents. Financial assistance may be available to patients receiving non-elective (emergent) hospital services who are not covered by any form of insurance or government program.

Verification of income and financial information is required. Click a tab below to view and download the requirements and application.

You must be a resident of Columbia County for 90 days.

Please provide a document dated (90) days old but not over (1) year old. Examples: old hospital bill, electric bill, pharmacy printout, etc.
All documentation presented for proof of residency must show name, same address as Financial Status Form.

Application download Requirements checklist

 

Florida Drivers License/FL Identification card
(No out of state identification will be accepted)

OR (2) two of the following:

  • Birth certificate
  • Voter’s registration card
  • Alien registration card
  • Affidavit of Identification (notarized)
Application download Requirements checklist

 

Please bring all that apply to you.

  • Most recent tax return, 1040 (including supporting schedules) and W-2’s for all wage earners in household
  • Pay stubs for previous 12 weeks or Income Verification Form-Employer
  • Bank Statements (previous 3 months for all accounts) (include all pages)
  • Medicaid Denial Letter or Medicaid application/case number
  • Unemployment/Workers Comp Statement
  • Child Support/Alimony
  • Social Security Benefits for any family member
  • Pensions/Retirement/Interest
  • Veterans Benefits
  • Any settlements, court ordered or otherwise
  • Other appropriate supporting documents
  • Self employment
    1. 1. Bank statements for all business accounts (3 mos.)
    2. 2. Previous year’s business tax return (complete w/attachments/schedules)
    3. 3. Current business financial statements
  • Assets
    1. 1. Checking and savings accounts
    2. 2. Equity value of real property other than homestead
    3. 3. Cash surrender value of life insurance if combined face value of all policies owned by the family unit exceeds $1,500.
    4. 4. Additional automobiles, motorized vehicles, motorcycles
    5. 5. Recreational vehicles
Application download Requirements checklist

 

PLEASE FILL OUT ENTIRE APPLICATION. DO NOT TURN IN AN APPLICATION WITH BLANK SPACES.

Once eligibility process has been completed ...

A photo ID card will be issued to the applicant and can be used to receive healthcare services at:

Download our financial assistance application now

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