As part of Nicklaus Children's mission to provide compassionate, accessible, high-quality, cost- effective healthcare to the community, we recognize some patients and families may need financial assistance to help with the cost of health care services. Therefore, Nicklaus Children's offers patient financial assistance to ensure access to high-quality health care for all.
Eligibility and Assistance Offered
Patients who are denied Medicaid coverage, or who are screened and do not meet the Medicaid guidelines, will be considered for the Nicklaus Children's Patient Financial Assistance program. Patients to apply for assistance may submit an application and the supporting documentation to a Nicklaus Children's patient financial services representative or send to the address on the application.
The Federal Poverty Guidelines are updated yearly and are used to determine eligibility for Patient Financial Assistance. Patients will be asked to provide verification of household income along with the names of people residing in the household during the application process. This information is used to identify where the household falls within the Federal Poverty Level Guidelines (FPL). The FPL category will determine the amount you will pay toward your medical bill. For patients above 400% of the FPL, the uninsured rate applies. The uninsured rate is 50% of the amounts generally billed and is applied when an initial payment is made.
Applying for Patient Financial Assistance
The current Patient Financial Assistance policy and applications for financial assistance are accessible on this web page. In addition, printed copies of the entire Patient Financial Assistance Policy and application may be obtained at no cost by emailing us at nicklauscustomerservice@ensemblehp.com or by calling 860-963-6337.
Patients may request consideration for financial assistance within the proceeding 240 days from the first patient statement.
Financial Application Process and Forms
Nicklaus Children's Health System is committed to providing charitable care to those in need. The Financial Assistance program provides assistance to uninsured patients for medically necessary health care services. It applies only to facility charges and employed physician charges. The policy does not apply to private-practicing physician charges or other independent company billings.
Your eligibility is based on your household income and other resources. The Financial Evaluation & Request for Financial Assistance must be completed in its entirety so that we may determine if you are eligible for assistance.
In order to process your application, photocopies of one of the following documents are required for every member of your household. Your application will not be reviewed until this documentation is submitted.
- Paycheck stubs 3-12 months prior to date of service.
- If self-employed, Income tax returns and all schedules (for most recent year).
- Forms approving or denying unemployment compensation or workers' compensation (dated within the last 12 months).
- A written verification of wages from employer (dated within the last 60 days).
- A written verification from public welfare agencies or governmental agency which can attest to the income status for the past 12 months.
Also required are bank statements for all accounts (most recent months)
Application Documents
- Financial Assistance Policy | Spanish | Creole
- List of Providers (Attachment B)
- Financial Evaluation Application (Attachment C) | Spanish | Creole
- Financial Assistance Policy Summary
The completed application and supporting documentation should be mailed to:
Nicklaus Children's Hospital
ATTN: PFS - Public Benefits
PO Box 947192
Atlanta, GA 30394-7192