Quick guide to application requirements

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 follow-up from our team there. 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 and signed application. If you are married, spousal signature also is required.
• Last three months of bank statements for all banks. If you are married, include spousal statements.
• Description of need for financial assistance.
• Verification of current income. Note that if you are married, spousal information also is required.
• If currently employed: Provide tax statements — including all schedules and attachments — for last two filed years or, if not applicable, last two months of pay stubs. Note that we cannot accept tax transcripts or personal checks in place of pay stubs.
• If currently unemployed: Provide unemployment letter, unemployment benefits or termination letter.
• If retired: Provide documentation of Social Security benefits, pension or retirement income.
• Also include if applicable: Disability letter or Medicaid denial letter if uninsured.
• If an active student: Provide copies of most recent federal income tax return including all schedules for the parent or guarantor who claims you as a dependent.
• If you have existing medical debt to other health care providers, please list all debt in detail so that your account can be considered for catastrophic financial assistance.

Note: Not all documents are needed if you only incurred services at NHSC locations including Barron, Cameron, Rice Lake, Mondovi, Osseo, and Menomonie, Wisconsin, and Albert Lea, Minnesota, including behavioral health and Fountain Centers. See application for more information.

Mayo Clinic will not be able to determine eligibility for financial assistance without the above documentation. Failure to provide the requested information will result in a delay in processing and potential continuation of billing and collection activity. Please do not send documents that are altered, stapled or clipped, and please note that Mayo Clinic cannot return original documents to you.

If you need help or have questions, please contact our customer service team at 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.