Wellstar Financial Assistance Helper

Let’s get started

This takes about 10 minutes. When you finish, you get:

Your Wellstar Financial Assistance application, already filled in
Your own checklist of papers to bring
Any extra forms you need, like a support letter

Questions marked with * must be answered.

Have these close by if you can: your Social Security card, your pay stubs or benefit letters, and your bank balances. If you do not know an answer, you can leave it blank and write it in later.

Good to know: Wellstar needs every paper within 30 days of your application. If Wellstar approves you, help can cover 6 months before and 6 months after the day you are approved.

Would you rather write it by hand?

Step 1 of 9

About you

Type your full legal name, the way it is on your ID. Your Social Security number adds its own dashes. If you do not have one, uncheck the box.

Your full name

Date of birth

Social Security number

I have a Social Security number Do you live in the U.S.?

Step 2 of 9

Where do you live?

Street first, then city, state, and ZIP in their own boxes.

Street address

City

State

ZIP

Phone I do not have a phone

Other phone (you can skip this)

Wellstar patient number, if you know it

Wellstar hospital you went to

No Wellstar patient number? That is fine. Leave it blank.

Step 3 of 9

Your family

If you pick Married, boxes for your spouse will show up.

Are you married? People you claim on your taxes

Add one for each child or other person you claim. Do not add yourself or your spouse. If there is no one, skip this.

Have you applied for Medicaid? Can you get COBRA insurance from an old job?

Step 4 of 9

Did you file taxes last year?

This means a federal tax return for last year.

Did you file a federal tax return last year?

Step 5 of 9

Do you work right now?

Pick the one that fits best. This decides most of your checklist, so take your time.

My work right now

Not sure? Wellstar looks at the last 3 months. Pick what has been true for those 3 months, not only today. Pick no money coming in only if you have had no job, no benefits, and no cash help at all for 3 months.

Step 6 of 9

Any other money coming in?

Check all that your household gets. If none fit, check None.

If you know how much you get each month, type it. If not, leave it blank. You can write it in later.

Social Security $ each month

Pension $ each month

Child support $ each month

Alimony $ each month

Rent you collect $ each month

What the rental property is worth $

Step 7 of 9

Do you have a bank account?

You can type your balances now, or leave them blank and write them in later.

Do you have a bank account? Have you filed for bankruptcy in the last 3 years? Do you have CDs, stocks, bonds, a 401k, or other investments?

Checking balance $

Checking bank name

Savings balance $

Savings bank name

Money market balance $

Money market bank name

In the last 2 months, did you get a deposit over $100 that was not a paycheck?

For example: a gift, money you borrowed, a tax refund, or money from selling something. If not, pick No.

Step 8 of 9

Your living situation

Pick the one that fits. This tells us if you need a support letter.

Where I live

Step 9 of 9

Check, sign, and print

Here is your own checklist. Sign below, then print or download your packet.

Your signature

Sign in the box with your finger or mouse. Or leave it blank and sign the paper copy.

By signing, you say your answers are true.

Trouble logging in to the portal? Call or text us at 678-903-5103 and we’ll send you a new invitation or help you get in.