HealthPartners Medical Group Financial Assistance Application
Please answer each question as completely as possible.

Questions marked with an * are required.

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 Earned Income Statement, if tax return was not filed last year; these are provided by the Social Security Administration.
  • Applicant's two most recent paycheck stubs, 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.
Spouse/Significant other (if applicable):
  • Spouse's/Significant Other's most recent federal tax return (if separate from applicant).
  • Spouse's/Significant Other's Earned Income Statement, if tax return was not filed last year; these are provided by the Social Security Administration.
  • Spouse's/Significant Other's two most recent paycheck stubs, 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.
After review of your application and documentation, we will contact you if additional information or documents are required.
Your information
Your information
*Preferred method of follow-up contact:
*Preferred method of follow-up contact:
*Current marital status:
*Current marital status:
Names, ages, and relationships of additional household members:
Names, ages, and relationships of additional household members:
Do you have insurance to cover medical expenses?
Do you have insurance to cover medical expenses?
In relation to your medical bills, do you have a lawsuit or insurance claim because of an accident or injury?
In relation to your medical bills, do you have a lawsuit or insurance claim because of an accident or injury?
*Current employment status:
*Current employment status:
Please complete with information from current or most recent employer and wages
Please complete with information from current or most recent employer and wages
*Spouse/significant other employment status:
*Spouse/significant other employment status:
Do you receive alimony?
Do you receive alimony?
Do you receive child support?
Do you receive child support?
Do you receive social security or disability?
Do you receive social security or disability?
Do you receive unemployment?
Do you receive unemployment?
Do you receive interest/dividends?
Do you receive interest/dividends?
Do you receive a pension?
Do you receive a pension?
Do you receive farm or self-employment income?
Do you receive farm or self-employment income?
List other sources of income (per month):
I/we own the following motor vehicles:
I/we own the following motor vehicles:
List recreational vehicles, boats, campers, snowmobiles, etc:
List recreational vehicles, boats, campers, snowmobiles, etc:
Other assest owned
Other assest owned
Buying or renting your home?
Buying or renting your home?
Do you own other real estate?
Do you own other real estate?
Other monthly expenses/liabilities(e.g. medical bills, child support, alimony, daycare, real estate tax, pharmacy, medical supplies, etc.):
For purposes of this form, “HealthPartners” means HealthPartners Medical Group, Regions Hospital, Hudson Hospital & Clinics, Westfields Hospital, Lakeview Hospital, and any other entity that provides services at a HealthPartners family location.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 is subject to the guidelines of the HealthPartners entity from which I received my care. I certify that the above information is true and correct.I/We hereby authorize HealthPartners to review federal and state records of employment and income history, including State Employment Security Agency records. I/We also authorize HealthPartners to obtain a credit report through an authorized credit bureau. This authorization is in effect for one (1) year unless limited by state law. A photographic or carbon copy of the authorization (of the signatures(s) of the undersigned) may be accepted as the original and may be used as a duplicate original.
For purposes of this form, “HealthPartners” means HealthPartners Medical Group, Regions Hospital, Hudson Hospital & Clinics, Westfields Hospital, Lakeview Hospital, and any other entity that provides services at a HealthPartners family location.

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 is subject to the guidelines of the HealthPartners entity from which I received my care. I certify that the above information is true and correct.

I/We hereby authorize HealthPartners to review federal and state records of employment and income history, including State Employment Security Agency records. I/We also authorize HealthPartners to obtain a credit report through an authorized credit bureau. This authorization is in effect for one (1) year unless limited by state law. A photographic or carbon copy of the authorization (of the signatures(s) of the undersigned) may be accepted as the original and may be used as a duplicate original.
The following documentation is required at the same time you submit this application. Documents are uploaded at the end.ApplicantApplicant's most recent federal tax returnApplicant's Earned Income Statement, if tax return was not filed last year; these are provided by the Social Security AdministrationApplicant's two most recent paycheck stubs, earning statements or unemployment paperworkApplicant's Proof of Income Letter, Annual Cost of Living Adjustment or SSA-1099 form, if receiving disability incomeApplicant's copy of denial letter from the county, if applied for a Minnesota Health Care ProgramSpouse/Significant other (if applicable):Spouse's/Significant Other’s most recent federal tax return (if separate from applicant)Spouse's/Significant Other’s Earned Income Statement, if tax return was not filed last year; these are provided by the Social Security AdministrationSpouse's/significant Other's two most recent paycheck stubs, earning statements or unemployment paperworkSpouse's/significant Other's Proof of Income Letter, Annual Cost of Living Adjustment or SSA-1099 form, if receiving disability incomeIf you cannot attach your documents at this time, you can submit them via email to HPMGFinancialCounselor@HealthPartners.com, fax to 952-883-9620, or U.S. mail to HealthPartners Mail Stop 25508B, P.O. Box 1309, Minneapolis, MN 55440-1309. You may also drop off verifications at a HealthPartners Clinic. Your application will be denied if the documentation is not provided within 15 days.

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 Earned Income Statement, if tax return was not filed last year; these are provided by the Social Security Administration
  • Applicant's two most recent paycheck stubs, 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
Spouse/Significant other (if applicable):
  • Spouse's/Significant Other’s most recent federal tax return (if separate from applicant)
  • Spouse's/Significant Other’s Earned Income Statement, if tax return was not filed last year; these are provided by the Social Security Administration
  • Spouse's/significant Other's two most recent paycheck stubs, 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
If you cannot attach your documents at this time, you can submit them via email to HPMGFinancialCounselor@HealthPartners.com, fax to 952-883-9620, or U.S. mail to HealthPartners Mail Stop 25508B, P.O. Box 1309, Minneapolis, MN 55440-1309. You may also drop off verifications at a HealthPartners Clinic. Your application will be denied if the documentation is not provided within 15 days.