Thank you for your interest in applying for Mayo Clinic financial assistance. You may qualify for full or partial financial assistance. Completing the following application and providing the proper requested documentation helps Mayo Clinic determine if you qualify for financial assistance.
You also can apply for financial assistance through your Patient Online Services account, where you can upload all documents and receive status updates on your application. If you'd prefer not to use Patient Online Services to submit your application and supporting documentation, please complete this form in its entirety, including attestation and date of completion, and submit it with all supporting documentation in person, by mail or by fax.
Please note: The more complete your supporting documentation, the faster and more effectively we can assess options. This process is often delayed by incomplete documentation — please refer to the checklist below to make sure you include as much information as you can.
Checklist of requested documentation
- Completed application.
- Tax return from current or prior year (or W-2 if tax return is not available).
- Pay stubs (most recent month).
- Bank statements (most recent month for all accounts).
- Unemployment statements (if applicable).
- Social Security, pension or retirement benefits (if applicable).
- Copy of Medicaid application denial letter or Medicaid card (if applicable).
Patients seen only at Oakridge in Mondovi, Wisconsin or Albert Lea, Minnesota Behavioral Health can complete the application and attach copies of one of the following:
- Prior year W-2 (or Form 4506-T if W-2 is not filed).
- Two most recent pay stubs.
- Income verification from employer.
Please do not send documents that are altered, stapled or clipped. Please note that Mayo Clinic cannot return original documents to you.
Mayo Clinic has financial counseling resources available to assist you with your financial assistance application without the need for an appointment. To speak with a financial counselor, please call 844-217-9591 (toll-free), Monday through Friday, 8 a.m. to 5 p.m.
Send documentation to Patient Account Services:
By Fax:
507-284-3445
By Mail:
Mayo Clinic Rochester
RO WE 01 800K-R
200 First Street SW
Rochester, MN 55905-0001
If you would like to submit your completed application and documents in person, please do so at any of our offices on the Arizona, Florida or Minnesota campus. Please submit documents in an envelope and ensure they are not altered, stapled or clipped. Please also note that we will be unable to make copies of documents for you.
