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.
Please return completed application and documents to the clinic or hospital where you are requesting assistance.
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