Financial Assistance

Financial Assistance Application
Click the buttons below to download the Northside Hospital Financial Assistance Application, available in English and Spanish. Financial Assistance Application- Electronic Submission
Financial Assistance Application - English
Financial Assistance Application - Spanish

Financial Assistance Mailing Address

All completed Financial Assistance Applications should be mailed to the following address:

Northside Hospital Business Office
Attention: Financial Assistance
1001 Summit Blvd NE Suite 150
Atlanta, Georgia 30319


Northside Hospital, Inc. and its tax-exempt affiliates (“Northside”) are committed to fulfilling their charitable mission as a not-for-profit health care provider. Uninsured, underinsured and medically indigent patients having limited or inadequate resources to pay for health care services rendered at a Northside Facility may be eligible for financial assistance through Northside’s Financial Assistance Program.

Financial Assistance is Available for Medically Necessary Services

Financial assistance may be available to patients who (i) reside in the states of Georgia, Alabama, Florida, North Carolina, South Carolina or Tennessee, and (ii) received emergency or medically necessary health care services at a Northside Facility. Medically necessary services are inpatient or outpatient health care services provided for the purpose of evaluation, diagnosis and/or treatment of an injury, illness, disease or its symptoms which, if otherwise left untreated, would pose a threat to the patient’s ongoing health or well-being. Each request for financial assistance will be reviewed independently and allowances may be made for extenuating circumstances on a case-by-case basis.

Financial Assistance Eligibility Determination Process

To be considered for financial assistance under Northside’s Financial Assistance Program, a patient may be screened verbally prior to admission over the phone or in the emergency department, or a patient must complete Northside’s Financial Assistance Application (English) (Spanish) and provide Northside with financial and other information necessary to support a patient’s eligibility for financial assistance. (If you select to submit your form electronically to cover an outstanding balance, please ensure to include your 11 digit alphanumeric encounter number. If you do not know your account number please contact our office at 404-851-6500). More specifically, patients will be required to provide proof of residency in one of the following states: Georgia, Alabama, Florida, North Carolina, South Carolina, or Tennessee. For non-us citizens, in certain crisis circumstances refugees may qualify for Financial Assistance. Additionally, patients may be asked to provide, if applicable:

Note: Patients will be asked to manually redact their SSN on any copy of supporting documentation. If personnel receive copies of supporting documentation that contain patients’ SSN, they will black out the SSN.

  • Most recent bank statements for personal and business checking and savings accounts
  • Recent pay stub(s) with validation of pay frequency
  • Current year W-2 form and/or recent year tax return
  • Written verification of wage from employer
  • Written verification from public welfare agencies or other government agencies which can attest to the Patients Gross Income status for the past 12 months
  • Social Security Award Letter
  • Verification of Pension or Retirement Income
  • Alimony and/or Child Support Court Order or Divorce Decree
  • Unemployment Income Notice
  • State separation notice and status of unemployment filing
  • Notarized Letter of Support: If the Patient has no Gross Income he or she should provide written documentation from person(s) or entities who provide him or her daily living necessities (food, shelter, clothing)
  • Verification of student status which is defined as a copy of current class schedule, registration information and a copy of the student photo ID
  • Monthly expenses (e.g., utilities, auto payment, insurance, loans, credit cards)
  • Patients seeking assistance due to medical indigency may need to submit evidence of assets

After receiving a patient’s application for financial assistance and supporting financial information or other documentation needed to determine eligibility for assistance, Northside will provide written notification regarding the determination within thirty (30) to sixty (60) days of receiving the request. Incomplete applications will be denied and a letter indicating what information is missing will be sent to the applicant. Upon receipt of the missing information, Northside will reconsider the application. Applicants may appeal denials of financial assistance by submitting an appeal request in writing. An appeal form will be included with the letter denying financial assistance.

In the event that a patient needs services on an urgent basis, Northside will work with the patient process any such request for financial assistance on an expedited basis.

Northside will offer financial assistance adjustments to patients who meet the established Financial Assistance Program guidelines and have completed the appropriate application. Additionally, Northside may discuss with patients the availability of government or other assistance programs as appropriate and assist patients in evaluating their eligibility for such programs.

Patients who present with Out of State Medicaid coverage for services via the Emergency Department are eligible to receive a full discount on care. 

Patients with annual household income less than or equal to 300 percent of the Federal Poverty Income Level may qualify to receive a full discount on care if they meet Northside’s Financial Assistance Program guidelines. Income, assets, debt and expenses will be evaluated for financial assistance approval. Patients who are insured or have a third party liability claim are only eligible to apply for financial assistance in the event they have a remaining balance after all payment resources are exhausted. Additionally, Northside may, within its discretion, fully discount care for medically indigent patients, whose medical or hospital bills from all related and unrelated health care providers, after payment by all third-party sources, would cause the Patient significant financial hardship.

Additionally, in certain instances  and within Northside’s  discretion, Northside may utilize a third-party to help identify patients that qualify for financial assistance based on publicly available patient information (e.g., participation in state-funded prescription programs, participation in the Women, Infants and Children (WIC) program, participation in the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), subsidized school lunch program eligibility, or eligibility for other state or local assistance programs). Patients identified as eligible to receive financial assistance by a third-party will not be required to complete the Financial Assistance Application.

All financial assistance approvals will continue to be valid for six (6) months, unless a change in the patient’s circumstances would void their eligibility. Additionally, Northside may request information to confirm that a patient’s financial circumstances continue to meet the Financial Assistance Program guidelines.

Please note that Northside will treat all applications, supporting documentation, communications and information obtained by third-parties with the highest regard for patient confidentiality.

Financial Assistance Mailing Address

All completed Financial Assistance Applications should be mailed to the following address:

Northside Hospital Business Office
Attention: Financial Assistance
1001 Summit Blvd NE Suite 150
Atlanta, Georgia 30319

Amounts Generally Billed

Northside does not charge any patient that qualifies for financial assistance more than Amounts Generally Billed (“AGB”).

AGB is calculated by multiplying the full price for medical care that is uniformly applied for services, before contractual discounts or deductions (“Gross Charges”), by the AGB percentage.

  • The AGB percentage is calculated by dividing (i) the sum of claims paid in full for emergency and other medically necessary care for Medicare Fee-For-Service and all primary payer private health insurers for the prior 12-month period by (ii) the sum of the associated Gross Charges for these claims.
  • Northside’s current AGB percentage is 32%. Accordingly, if a patient qualifies for financial assistance for services received at a Northside Facility, the most the patient will be charged is 32% of Gross Charges (e.g., if a patient’s Gross Charges are $10,000, the most the patient will be charged for these services is $3,200).

Billing and Collections

If a patient is responsible for all or part of the cost of services received at a Northside Facility, Northside will attempt to bill and collect from the patient.

  • If after 120 days a patient has not made a payment on a bill, Northside will refer the patient’s account to a primary collections agency.
  • The primary collections agency will subsequently attempt to collect payment from the patient. During this process, the primary collections agency will analyze a patient’s assets and ability to pay and recommend to Northside whether legal proceedings to collect for the services should be taken. Northside will evaluate this recommendation and depending on the circumstances, may initiate legal proceedings to collect for the services rendered.
  • If the primary collections agency is unable to collect from the patient after sixty (60) days and legal proceedings are not recommended, the primary collections agency will refer the account to a secondary collections agency.
  • The secondary collections agency will attempt to collect on the account.
  • If the secondary collections agency is unable to collect on the account, the account will be referred back to Northside, at which point no further action will be taken.

Northside Providers Not Subject to the FAP

Certain services provided at a Northside Facility by a physician, physician assistant, nurse anesthetist or other professionals are not covered under Northside’s FAP. Specifically, services provided in the following departments by the following providers, are not covered by the Financial Assistance Program:

  • Emergency Department Services provided by Emergency Department Physician Services, Cherokee Emergency Services LLC, or Gwinnett Emergency Specialists, PC
  • Pathology Department Services provided by Pathology & Lab Medicine (PALM) or Gwinnett Pathology Associates
  • Radiology Department Services provided by Northside Radiology Associates or North Metropolitan Radiology Associates 
  • Neonatal or Perinatal Services provided by Neonatology (Pediatrix), Atlanta Perinatal Consultants, Maternal-Fetal Specialists (MEDNAX) or Gwinnett Neonatology
  • Psychiatric Services provided by Neuropsychiatric Consultants 

Additional Information Regarding Northside’s Financial Assistance Program

Northside will widely distribute this policy to the public by posting a copy on Northside’s website and posting a copy in Northside’s Emergency Departments, registration areas and waiting rooms. Northside will also include a reference to the link on the website where the policy and application can be found in the pre-admission welcome letter. Additionally, Northside’s Financial Assistance Application and appeal form may be obtained by:

Contacting or visiting one of Northside’s Financial Counseling Offices between the hours of 9:00 a.m. and 4:00 p.m., Monday through Friday:

  • Atlanta Financial Counseling Office – 404-851-8589, located at 1000 Johnson Ferry Road, Atlanta, Georgia 30342
  • Forsyth Financial Counseling Office – 770-844-3246, located at 1200 Northside Forsyth Drive, Cumming, Georgia 30041
  • Cherokee Financial Counseling Office – 770-224-1979, located at 450 Northside Cherokee Boulevard, Canton Georgia 30115
  • Duluth Financial Counseling Office – 678-312-3200, located at 3620 Howell Ferry Rd, Duluth, Georgia 30096
  • Gwinnett Financial Counseling Office – 678-312-4406, located at 1000 Medical Center Boulevard, Lawrenceville, GA 30046

Georgia Pathway to Coverage

Georgia Gateway is an alternative for self-pay patients who do not have insurance coverage. 

Criteria for Qualification 

  • For Individuals between 19-64 years old
  • Income between 0-95% FPL (100% with 5% disregard)
  • Must Meet Qualifying Activities Requirement
  • Premium Payment Requirement
  • Citizenship, Residency, and Satisfactory Immigration Status requirements
  • Not be incarcerated
  • Not eligible for any other type of Medicaid
  • No Retro eligibility is allowed with this program.

Qualifying Activities 

  • 80 hours minimum within a two period to be reported b phone, mail, online, or in-person:
    • Unsubsidized Employment
    • Subsidized Private Employment (includes self-employment)
    • On-the-job Training
    • Job Readiness Activities
    • Community Service Activities
    • Vocational Educational Training
    • Enrollment in Higher Education
  • Applicant must report their hours by the 17th of each month to be eligible the following month.

Additional Information

  • Individuals with disabilities that did not qualify for SSA or Adult Medical Necessity programs can apply.
  • If employed, the applicant must enroll in employer-sponsored insurance programs. The state will apply cost-sharing mechanisms toward the premiums.
  • If employer coverage is deemed to not be cost-effective, the individual can default to the state MCO plan.
  • Premium Payments are estimated to be approx. $7-11/month for 50-100% FPL.
  • Waiver is designed to be in place for 5 years and is then subject to review for continuance.
  • A member denied for Aged, Blind, or Disabled benefits, via Gateway, will be subject to review for this program prior to receiving a final denial.

More information at:

Northside Billing Resources


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