Financial Assistance Application

Applicant Information

Identify your relationship to the patient (optional - check all that apply)

I am the patient I am responsible for the patient's medical expenses

Applicant first name

Applicant middle name or initial (if not applicable, enter "not applicable")

Applicant last name

Patient Information

Patient's first name

Patient's middle name or initial (if not applicable, enter "not applicable")

Patient's last name

Patient's birth date

Mayo Clinic Number (optional)

Mayo Clinic location (optional)

The Mayo Clinic location where patient is receiving services or would like to receive services.

Spouse or Partner (Used to identify all patient accounts eligible for financial assistance)

Do you have a spouse or partner?

Yes No

Spouse/partner's first name

Spouse/partner's middle name or initial

Spouse/partner's last name

Spouse/partner's birth date

Employment status

Full time Part time Self employed Unemployed Student

Dependents

Provide the legal names, relationship and birthdates of any dependents of the Patient and/or Responsible Party. Type 'None' if nothing is applicable.

Other Income

Describe other sources of income, include monthly income amount, of the Patient and/or Responsible Party. Type 'None' if nothing is applicable.

Medical Debt

Describe all medical debt. Include the name of hospital, medical doctor, unpaid balance and monthly payment details. Type 'None' if nothing is applicable.

Certification/Acknowledgement

I certify that all information listed is true and correct to the best of my knowledge. I understand that the information is to be used to ascertain my ability to pay for services provided by Mayo Clinic or an affiliated entity and I give permission to Mayo Clinic and all affiliated clinics, hospitals and entities to share the information as necessary to consider my financial assistance request. I hereby grant permission to Mayo Clinic, all Mayo Clinic affiliates and representatives or agents to investigate the information contained herein.

ErrorSelect to certify and acknowledge.

Name