Guarantor / Account #:
______________________________
Uninsured Discount/Financial Assistance Application Instructions
Thank you for your interest in North Memorial Health Care/Maple Grove Hospital’s Uninsured Discount/Financial
Assistance program. Enclosed you will find the Uninsured Discount/Financial Assistance application. Please keep the
following in mind while completing the application:
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Uninsured discounts are applicable for any uninsured hospital based treatment that is medically necessary and not
deemed cosmetic and the patient’s household income is less than $125,000. Uninsured discounts are not
applicable to North Memorial Transportation accounts.
Financial Assistance is not health insurance, and is a financial assistance program for your North Memorial Health
Care/Maple Grove Hospital or North Memorial Transportation bills only. Our program can only cover services that
are billed directly through North Memorial Health Care/Maple Grove Hospital. This means that our program can
only assist with charges for North Memorial Health Care/Maple Grove Hospital facilities, and charges incurred with
doctors employed by North Memorial Health Care.
Financial Assistance can assist with your bills for medically necessary services, and does not assist with bills for
prescription medications, retail services, and elective services. Auto Accident and Workers Compensation balances
are excluded as well.
When applying for an uninsured discount, please provide your proof of income and most recent tax forms.
When filling out the application for financial assistance, it is important that you provide us with your current
insurance, income, and asset information, even if your situation has changed since you incurred your bills with
North Memorial Health Care/Maple Grove Hospital or North Memorial Transportation. Financial Assistance is based
on your current house hold size, income, and assets.
Please use this table as a checklist when completing the enclosed application.
Section 1
Applicant Information
Section 2
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Application must be fully completed – ALL BOXES NEED TO BE FILLED IN.
The information on the application has to match the supporting documentation EXACTLY.
The application must be signed and dated by the primary applicant.
If you were claimed as a dependent on someone else’s tax return, the application is to be completed by that
person and returned with all supporting documents.
Dependent Inclusion
Section 3
Proof of Insurance
Coverage
Section 4
Proof of Liquid Asset
Balance
IF NO HEALTH INSURANCE, YOU WILL NEED:
 Medical Assistance and/or MN Care written determination.
 Proof of insurance coverage or proof of exemption from the Affordable Care Act regulations.
We need clear photocopies (do not send originals as they will not be returned) of the following:
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Section 5,6,7,8
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Proof of Income
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**Send copies of
ALL that apply**
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Bank Statements, stocks/bonds, CD’s, money market accounts.
Please provide Property Tax statement and mortgage statement for primary residence and real estate
owned.
Please send us a complete statement for all checked items. It must include your name, institution name, all
transactions, a current balance and a date. The information in Section 4 must match exactly what your
supporting documentation shows.
Previous year’s federal tax return with Schedules C, E, & F. Do not send W2’s or state tax
returns. For a copy of your Federal return, call 800-829-0922.
A copy of unemployment benefits (if applicable).
***If you are retired and collect Social Security, Pension, or Annuities, please list the information in
Section 7 and send proof. You may contact Social Security Administration at 800-772-1213.
If the applicant(s) have no income at all, a shelter statement must be completed – Call our office to obtain a
copy if needed.
If you are unsure about what documentation to include with your application, or if you need any other assistance,
please contact the appropriate number below:
North Memorial Health Care/Maple Grove Hospital
3300 Oakdale Ave N – Financial Assistance
Robbinsdale, MN 55422
(763)581-4480 or (866) 358-2644
North Memorial Transportation
4501 68th Ave N
Brooklyn Center, MN 55429
(763)581-9930 or (800)535-6720
Sincerely,
Financial Assistance Team
XF5625 01/2016
Guarantor / Account #:
______________________________
Uninsured Discount/Financial Assistance Application
1.
PRIMARY APPLICANT: (If applying for a minor child, enter YOUR name here, and list the child as a dependent in Section 2 below)
First Name
M.I.
Last Name
Date of Birth
Address
Sex
M
State
City
Are you a U.S. Citizen?
Yes
No
Social Security Number
Home Phone
Marital Status
F
Zip Code
Other Phone
2. PERSONS LIVING WITH YOU FOR WHOM YOU ARE FINANCIALLY RESPONSIBLE:
Do you have a spouse and/or any dependents living in your home?
No
Yes – If YES, fill in below
*We need to consider your entire household when reviewing for Financial Assistance
NAME (First, M.I., Last)
Date of Birth
Relationship to You
3. HEALTH INSURANCE INFORMATION Please answer the following questions for yourself, as well as everyone you listed above in
Section 2 and attach a copy of each person’s insurance card.
**REQUIRED HEALTH INSURANCE DOCUMENTATION**: If anyone listed on this application does not have medical coverage (Medical Assistance,
MN Care, Medicare, or Other). Please provide written explanation regarding why insurance was not obtained and a current & valid determination
letter from MN Care for that person, or documentation regarding exemption from the Affordable Care Act Regulations.
Please send a copy of the front and back of the insurance card listing each person that is covered by that insurance.
Do you have Medicare?
No
Part A
Part B
Does your spouse have Medicare?
No
Part A
Part B
Does anyone have Medical Assistance or
IF Yes, who has MA or MN Care?
Minnesota Care?
No
Yes
Does anyone have additional health
IF YES, what is the name and phone # of the insurance and who is covered?
insurance?
No
Yes
4.
PLEASE INDICATE WHICH OF THE FOLLOWING ACCOUNT TYPES OR ASSETS YOU HAVE?
Primary Residence
Recreational Vehicle(s)
Real Estate
Stocks/Bonds
401K/403B/IRA
Checking Acct.
Savings Accts.
No Assets
Certificate of Deposit (CD)
Money Market Accts.
HRA/HSA
**REQUIRED ASSET VERIFICATION DOCUMENTS **: YOU MUST PROVIDE YOUR MOST RECENT STATEMENT(S) VERIFYING THE BALANCE/VALUE OF
EACH ASSET LISTED BELOW. EACH STATEMENT MUST CLEARLY IDENTIFY YOU AS THE OWNER OF THE ASSET. THE STATEMENT DATE(S) MUST BE
RECORDED IN COLUMN a. OF THE BELOW GRID. ***Please provide Property Tax & Mortgage statement for primary residence and real
estate owned***
a. Statement Date
b. Asset Owner’s Name
c. Type of Asset
d. Asset Value
e. Name of Financial Institution
APPLICATION CONTINUED ON REVERSE SIDE
XF5625 01/2016
Guarantor / Account #:
______________________________
4. ACCOUNT TYPES & ASSETS continued…
a. Statement
date
b. Asset Owner’s Name
c. Type of Asset
d. Asset Value
e. Name of Financial Institution
5. EMPLOYMENT VERIFICATION:
Are you employed?
No
Yes – If YES, fill in below
Is your spouse employed?
No
Yes – If YES, fill in below
**REQUIRED EMPLOYMENT INCOME VERIFICATION DOCUMENTS **: YOU MUST PROVIDE A COPY OF YOUR PREVIOUS YEAR’S FEDERAL INCOME
TAX FORM 1040 INCLUDING SCHEDULES C, E, & F.
a. Employed Worker’s Name
b. Employer/Business Name
c. Hourly wage/Salary
d. Hours worked per week
d. Tips
6. ALL OTHER INCOME:
Social Security Unemployment
Supplemental Security Income (SSI)
Trusts
Any other income
Retirement/Pension
Dividends
**REQUIRED VERIFICATION DOCUMENTS FOR OTHER SOURCES OF INCOME**:
 SOCIAL SECURITY, SSI, PENSION, UNEMPLOYMENT, and WORKER’S COMPENSATION: Send your proof of benefits statement or award
letter showing how much you receive each month.
 ALL OTHER SOURCES OF INCOME: Provide either (1) tax documents showing income received, or (2) some other form of “official”
documentation verifying the income and source.
 A copy of your bank statement is not acceptable as proof of income.
 Provide a copy of your previous year’s federal tax income form 1040 including schedules C, E, & F.
7. IF APPLICANT HAS NO INCOME REPORTED, A SHELTER STATEMENT OF SUPPORT MUST BE COMPLETED. PLEASE CALL OUR
OFFICE TO OBTAIN A COPY. If you have additional factors that you would like us to consider with your application, please list
them below or use an addition piece of paper.
*****BEFORE RETURNING THIS APPLICATION, MAKE SURE YOU HAVE ATTACHED ALL REQUIRED
DOCUMENTATION AS OUTLINED IN EACH SECTION***** Incomplete applications cannot be processed.
I acknowledge that the information of this application is true and correct to the best of my knowledge. I understand that misrepresentation of the information on
this application could result in denial of your financial assistance application request.
DATE:
PRIMARY APPLICANT’S SIGNATURE:
X
Please allow 30-45 days for processing. You will receive notification by mail of our decision.
XF5625 01/2016