Financial Assistance Forms
If you have questions or need assistance completing the application, please contact your hospital or clinic business office.
Find a location
Avera has a financial assistance policy if you meet certain requirements and are unable to pay your bill.
How to Request Assistance
- Contact the clinic or hospital business office at the phone number listed on your bill.
- Complete the Avera Financial Assistance Application (English)(Spanish) and the Consent to County Release Form (English)(Spanish).
- Return application with the most recent copies of your W-2, Tax Returns, Pay Stubs and Bank Statements to your clinic or hospital for review.
For Patients of Avera Marshall Regional Medical Center, Marshall, MN