Financial Assistance


Financial Assistance Policy 

Tift Regional Health System, Inc. (TRHS), a not-for-profit health system, was established to serve the health needs of the patients and communities we serve. TRHS is committed to providing health services to patients regardless of their ability to pay. TRHS recognizes that not all patients have the financial resources to pay their hospital bill. 

The Financial Assistance Program offers emergency and other medically necessary services at no cost to qualified patients. Whether patients are uninsured or underinsured, they can apply for financial assistance. Our Financial Counseling staff and a third party service will assist individuals in applying for eligible government health insurance programs and completing the financial assistance application, free of charge. Upon approval patients may receive the following assistance:


2021 Federal Poverty Guidelines (FPG)
Indigent/Charity Income Levels


How to Obtain Copies of our Financial Assistance Program Policy and Application

You may obtain a copy of our policy and application form free of charge in the following ways:

  • Click below to download the form



  •  Additional Forms

Dependent Attestation (English)

Dependent Attestation (Spanish)

Statement of No Income (English)

Statement of No Income (Spanish)

Income Support Statement (English)

Income Support Statement (Spanish)


Visit our Financial Counseling office located at:

Tifton Physicians Center
907 E. 18th Street Suite 190
Tifton, GA 31794

  • Request copies to be mailed or sent electronically by calling (229) 353-6124, option 2; or, send an e-mail to
  • Also available at:

Southwell Medical Clinic Registration
Tift Regional Outpatient Registration
Southwell Medical Registration
Our Emergency Department

Providers who are not covered under the Financial Assistance Policy

Certain physicians are not covered under the TRHS Financial Assistance policy. Please click on the link below (Appendix A) for a complete list or contact us at (229) 353-6124, option 2 for more information.

Return your completed application to:

Financial Counseling Unit
P.O. Box 807
Tifton, GA 31793

If approved, financial assistance will apply to:

Tift Regional Medical Center

Tift Regional Medical Center West Campus

Southwell Medical

Important: Patients/guarantors may apply for financial assistance at any time up to two hundred forty (240) days after the first post-discharge billing statement is available.

Want to know if you qualify for Medicaid?

Click here to fill out a questionnaire to find out.

Price Estimates

How to Obtain a Price Estimate in Advance of Services