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Uncompensated Care Application Form

Head of Household or Guarantor Information

Are you applying for an Uncompensated Care discount?
Spouse and Legal Dependents
Last Name
First Name
Applying for Uncompensated Care discount?
Is everyone applying a US citizen or US National?
Last name
First name
Immigration status
Date entered the US
Employment/Work History - Head of Household

Please include all employment information for the past 30 days.

Other Income
Please submit supporting documentation with your completed application.
Income Type Monthly Amount
No Income
Liquid Assets

(Stocks, Bonds, Checking, Savings, Money Market, Certificate of Deposit accounts) Liquid asset information is not collected for outpatient discounts

Name of Financial Institution
Account Type
Owner(s) Name
Current Balance

  1. I, the undersigned, certify that the completed information in this document is true and accurate to the best of my knowledge. 

  2. I will apply for any and all assistance that may be available to help pay this bill. 

  3. I understand the information submitted is subject to verification; therefore, I grant permission and authorize any bank, insurance co., financial institution and credit grantors of any kind to disclose to any authorized agent of Hennepin Healthcare information as to my past and present accounts, policies, experiences and all pertinent information related thereto.

  4. I understand that I might be asked to provide documentation to verify my information. 

  5. If the application is incomplete, it will be returned. We will not be responsible for follow-up on incomplete applications.  

  6. If you do not qualify for Uncompensated Care or have any copays or deposit balances remaining after 90 days from the service date, your balance may be placed with a collection agency. If your balance is not paid to the collection agency, Hennepin Healthcare is authorized to place your balance with the Department of Revenue. During this time any state taxes, property taxes, or lottery winnings will be forwarded to Hennepin Heatlhcare to satisfy your outstanding balance. 
, I certify that checking this box the equivalent of my signature.
, I certify that checking this box the equivalent of my signature.