Financial Assistance Forms
Avera has a policy and program in place to offer financial assistance to patients who qualify. Qualification depends on meeting certain requirements. If you’re unable to pay your bill, see if you’re eligible for aid.
How to Request Financial Aid
- Contact the business office of the clinic or hospital (phone number listed on your bill) where you received care. Let them know you’re requesting financial assistance.
- Complete the Avera Financial Assistance Application (English / Spanish).
- Complete the Consent to County Release Form (English / Spanish).
- Mail completed applications and forms with your most recent W-2, tax returns, pay stubs and bank statements to your clinic or hospital for review. Send this to the mailing address listed on your billing statement.
Questions? Reach Out.
If you need help completing the financial assistance form, please contact your hospital or clinic business office.
Financial Assistance & Policy Details
Read and review financial assistance and policy guidelines so you’re well aware of what to expect.
Receive Care in Marshall, MN?
If you received medical care at the Avera Marshall Regional Medical Center, you may request for determination of eligibility for uninsured discount.
Still Need Help?
Our billing team is here to assist. Give us a call at 888-370-6525 from 7AM to 5PM Monday through Friday.