MyErlangerHealth HealthLink Plus For Vendors For the Media Physician Relations and Recruitment
975 East Third Street
Chattanooga, TN 37403
Children's Hospital at Erlanger Erlanger Baroness Campus Erlanger Bledsoe Campus Erlanger East Campus Erlanger North Campus UT Erlanger Physicians Group

Online Prereg
Register for a Class or Event
New Foundations Page
Print   Email

Charity Application

CLICK HERE to download the Erlanger Charity Application

The following information must be provided in order to be considered under the Erlanger Charity Policy:

  1. The last 4 paycheck stubs
  2. Documentation of Social Security benefits
  3. Unemployment benefits
  4. Retirement income
  5. Food stamp income worksheet
  6. Latest bank statement
  7. Recent check stub
  8. Latest income tax return

You MUST include all information listed above that pertains to you. A hardship letter explaining your current circumstances can be included to justify your inability to pay.

If this information is not returned with the application, it will be considered incomplete and returned to you. The application will need to be returned to Erlanger Health System within fourteen (14) days from the date sent to you. If it is not returned within this time, you will need to reapply. A stamped, self-addressed envelope has been provided to return the completed application and documentation.

Please mail completed application to the address listed below. Contact Shemeca Lewis at 423-778-4764 or Stacey Mobley at 423-778-4746 with questions or for additional information.

Erlanger Health System 
Charity Application
Attention: Shemeca Lewis
P.O. Box 1150
Chattanooga, TN 37401

Patient Financial Services Department
or 800-262-5764
8:30 a.m. - 4:30 p.m.
Monday - Friday

Erlanger Health System
P.O. Box 1150
Chattanooga, TN 37401