HealthPartners Financial Assistance Application

Please answer each question as completely as possible.

All fields are required unless marked optional.
The following documentation is required at the same time you submit this application. Documents are uploaded at the end.

Applicant:

Applicant's most recent federal tax return
Applicant's Social Security Statement, if tax return was not filed last year; these are provided by the Social Security Administration.
Applicant's last 60 days of paystubs, earning statements or unemployment paperwork.
Applicant's Proof of Income Letter, Annual Cost of Living Adjustment or SSA-1099 form, if receiving disability income.
Applicant's copy of denial letter from the county, if applied for a Minnesota Health Care Program.
Applicant's latest financial statement supporting liquid asset holdings

Spouse/Significant other (if applicable):

Spouse's/Significant Other's most recent federal tax return (if separate from applicant).
Spouse's/Significant Other's Social Security Statement, if tax return was not filed last year; these are provided by the Social Security Administration.
Spouse's/Significant Other's last 60 days of paystubs, earning statements or unemployment paperwork.
Spouse's/Significant Other's Proof of Income Letter, Annual Cost of Living Adjustment or SSA-1099 form, if receiving disability income.
Spouse's/Significant Other's latest financial statement supporting liquid asset holdings

After review of your application and documentation, we will contact you if additional information or documents are required.

Frequently asked questions:

How do I qualify for the financial assistance program?
- We review your application, required income and asset documentation, and family size to determine if you qualify for a discount. Contact us with questions.

Whose income must be included with the application for financial assistance?
- If married, both spouses’ incomes are included. Proof of separation required. If someone claims you on their tax return you must send in their income information as well.

Can I apply for financial assistance if I have insurance?
- Yes, the discount is applied after we receive payment from your insurance company.
Will my services qualify for a financial discount?
- Not all services are eligible for our financial assistance program. Some exclusions are cosmetic, elective, and not medically necessary services. Balances that would be paid by insurance like Medicare, Medicaid, automobile, worker’s compensation, or liability insurance are also excluded.

Financial Assistance Application location: (Choose the location where services were received and where the bills are coming from. This is the location that will review your application.)

HealthPartners Clinics

Park Nicollet Health Services (including Methodist Hospital, Methodist Hospital Home Care and Hospice, Park Nicollet Clinic, Park Nicollet Health Care Products, and TRIA Orthopedics)

Regions Hospital

Your information

Date of application (optional):

Name of person completing application (if different than applicant) (optional):

Relationship to Applicant (optional):

From this point, please complete the application with the applicant's (and his/her spouses's, if applicable and when requested) information.

Applicant Name:

Date of birth:

Street/mailing address:

City:

State:

Zip code:

Preferred telephone number:

Email:

Preferred method of follow-up contact:

Telephone

Postal mail

Telephone

Postal mail

Current marital status:

Single

Married

Other

If "Other," please specify:

Spouse/significant other name:

Spouse/significant other address (if different than applicant's) (optional):

Spouse/significant other city (if different than applicant's) (optional):

Spouse/significant other state (if different than applicant's) (optional):

Spouse/significant other zip code (if different than applicant's) (optional):

Spouse/significant other social security # (optional):

Spouse/significant other date of birth (optional):

Names, ages, and relationships of additional household members:

Name (optional):

Age (optional):

Relationship (optional):

Name (optional):

Age (optional):

Relationship (optional):

Name (optional):

Age (optional):

Relationship (optional):

Do you have insurance to cover medical expenses? (optional)

Yes

Primary Insurance

Health insurance company name:

Effective date:

Group number:

Policy number:

Secondary Insurance

Health insurance company name (optional):

Effective date (optional):

Group number (optional):

Policy number (optional):

In relation to your medical bills, do you have a lawsuit or insurance claim because of an accident or injury? (optional)

Yes

Name of attorney (optional):

Telephone number of your attorney (optional):

Current employment status:

Full time

Part time

Laid off

Other

If "Other," please specify:

Please complete with information from current or most recent employer and wages

Place of employment:

Address of employment: (optional)

City of employment: (optional)

State of employment: (optional)

Zip code of employment: (optional)

Hourly wage: $

Monthly wage: $

Hours per week:

Do you receive alimony?

Yes

Amount received monthly: $

Do you receive social security or disability?

Yes

Amount received monthly: $

Do you receive unemployment?

Yes

Amount received monthly: $

Do you receive interest/dividends?

Yes

Amount received monthly: $

Do you receive a pension?

Yes

Amount received monthly: $

Do you receive farm or self-employment income?

Yes

Amount received monthly: $

List other sources of income (per month) (optional):

Other assets owned (optional)

Estimated value for first asset: $

Amount owed for first asset: $

Monthly payment for first asset: $

Financial institution for first asset:

Estimated value for second asset: $

Amount owed for second asset: $

Monthly payment for second asset: $

Financial institution for second asset:

Estimated value for third asset: $

Amount owed for third asset: $

Monthly payment for third asset: $

Financial institution for third asset:

Where do you bank?

Checking balance: $

Savings balance: $

Other assets - cash on hand: $

Other assets - CD's: $

Other assets - stocks/bonds: $

Other assets - IRA's: $

For purposes of this application for financial assistance, “HealthPartners” includes any HealthPartners-affiliated hospital, clinic, or other care delivery site, including but not limited to:

Medical Groups: HealthPartners Medical Group, Park Nicollet Clinic, Stillwater Medical Group

Hospitals: Amery Hospital & Clinic (WI), Hudson Hospital & Clinic (WI), Hutchinson Health, Lakeview Hospital, Olivia Hospital & Clinic, Park Nicollet Methodist Hospital, Regions Hospital & Clinic, Westfields Hospital & Clinic (WI)

Other: Physicians Neck & Back Center, TRIA Orthopedics, HealthPartners Dental Group

I certify that the above information is true and correct. I understand that the information I have provided is subject to verification by HealthPartners, for review by federal and state agencies, and for other programs or related purposes. I also understand that my application and eligibility for financial assistance may be subject to the specific guidelines of the location from which I received my care.

Signature

Spouse/Significant Other Signature (if applicable)

File Attachment

The following documentation is required at the same time you submit this application. Documents are uploaded at the end.

Applicant

Applicant's most recent federal tax return
Applicant's Social Security Statement, if tax return was not filed last year; these are provided by the Social Security Administration
Applicant's last 60 days of paystubs, earning statements or unemployment paperwork
Applicant's Proof of Income Letter, Annual Cost of Living Adjustment or SSA-1099 form, if receiving disability income
Applicant's copy of denial letter from the county, if applied for a Minnesota Health Care Program
Applicant's latest financial statement supporting liquid asset holdings

Spouse/Significant other (if applicable):

Spouse's/Significant Other’s most recent federal tax return (if separate from applicant)
Spouse's/Significant Other’s Social Security Statement, if tax return was not filed last year; these are provided by the Social Security Administration
Spouse's/significant Other's last 60 days of paystubs, earning statements or unemployment paperwork
Spouse's/significant Other's Proof of Income Letter, Annual Cost of Living Adjustment or SSA-1099 form, if receiving disability income
Spouse's/Significant Other's latest financial statement supporting liquid asset holdings

If you cannot attach your documents at this time, you can submit them via email to RegionsBilling@HealthPartners.com, fax to 651-254-1684, or U.S. mail to HealthPartners P.O. Box 183, Minneapolis, MN 55480-0183. You may also drop off verifications at a Regions Hospital or hospital-based clinic. Your application will be denied if the documentation is not provided within 15 days.

Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. We recommend you send an encrypted email.

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