Financial Assistance Program
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We're ready to help
We are committed to providing quality health care that improves the health of those we serve and to provide excellent service. One of the ways we fulfill this mission is to provide financial assistance to those members of the community in need. The Financial Assistance Program may be able to assist with expenses for your care.
How can I qualify?
To find out if you qualify for financial assistance, please complete the Application Form and attach documents that prove income, assets or other available resources. If you need help completing the application, financial counselors are available by calling (256) 265-9569 between the hours of 9 a.m. and 4 p.m., Monday–Friday. All inquiries are confidential.
How do I apply?
Print and complete the Financial Assistance Application and send it to the Patient Accounting Department by mail to the following address:
Huntsville Hospital Patient Accounting
Attention: Financial Counselor
101 Sivley Road
Huntsville, AL 35801
Instructions
When completing the Financial Assistance Application, be sure to include documents that verify your income and assets for yourself and for your spouse (if applicable).
Examples of documentation used to verify eligibility include pay stubs, tax returns forms, bank statements, and medical bills owed. Additional forms of verification may be required.
Verification of Income
- If you are currently employed, please provide verification of gross income for the last three months. Verification can be a check stub or a letter from your employer on company letterhead.
- If you are self employed, please provide a complete copy of the prior tax year income tax return, including schedule C and all forms.
- If you are unemployed and drawing unemployment benefits, please provide verification of the amount you receive. Verification can be your unemployment benefit approval letter.
- If you are unemployed and have no income, please provide verification of your circumstances. Verification can be provided by a written statement from your physician, church pastor, or attorney.
- If you are drawing Social Security, SSI, Social Security Disability, or Veteran or Military Pension, please provide verification of income. Verification can be a copy of your most recent check stub or a letter from the government showing the amount you are drawing. If your minor children also receive a check, please provide verification of their income as well.
- If you are drawing a retirement check, pension, annuity, short/long term disability, or worker’s compensation, please provide verification that income. Verification can be a copy of your most recent check stub or a letter from the income source.
- If you receive Food Stamps, AFDC (Aid for Dependent Children), or FA (State-provided Family Assistance), please provide verification of the assistance. Verification can be your approval letter outlining your proof of eligibility.
- If you receive child support or alimony or receive assistance from your children's other parent (not living in the household), please provide verification of that income source. Verification can be a copy of your child support order or divorce decree.
- If you are separated and/or going through a divorce, please provide legal proof of separation.
- If your monthly expenses exceed your income, please provide verification of how your monthly expenses are being satisfied. Verification can be letters of financial support from your family, friends, church, or other organizations. If you are using credit cards, cash advances, or loans to satisfy your monthly expenses, please provide copies of the most recent statement of those items.
Verification of Assets
- Please provide the most recent copy of your complete bank statement (including all pages of all checking, savings, or certificates of deposits). If your bank account has been closed, please provide a letter from the bank stating your account has been closed.
- Other assets, such as real estate (other than your primary residence), rental income, or investment equity will be verified during the financial application process.
Eligibility
The hospital will determine financial assistance eligibility based upon income and asset guidelines and the Federal Poverty Income Guidelines. Approved applications apply to hospital accounts only.
Notification of Eligibility
Applicants will be notified by letter regarding their Financial Assistance application status.
Continued Collections
Please note that collections continue on your account until all required verification is received. If supporting documentation is not submitted with the financial statement and/or falsification of any portion of the application is identified, your application will be denied. The hospital reserves the right to reverse financial assistance when information is presented indicating the patient/guarantor has the ability to pay for services and financial assistance should not have been approved.
PLEASE NOTE: The financial assistance offered under this program does not apply to physician or other professional fees billed separately from the hospital fees.
For questions or assistance with the financial assistance application, please call our office at (256) 265-9569
The application is the printer-friendly PDF format. If you cannot view the application, download the Acrobat Reader for free.
