Follow the steps to complete your financial assistance application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select the entity for which you are applying for financial assistance. This includes various health services, such as Park Nicollet Health Services or Regions Hospital & Clinic. Make sure to check the appropriate box.
3. Enter your personal information in the designated fields. This includes your full name, date of birth, address, home phone number, city, state, ZIP code, and marital status. Ensure all information is accurate.
4. Provide information regarding your spouse or partner, if applicable. Fill in their name, date of birth, and checkboxes for their employment status.
5. List dependents claimed on your Federal taxes by entering their names, dates of birth, and relationships in the provided fields.
6. Indicate if you currently have insurance to cover medical expenses. If yes, provide the name of your primary and secondary insurance companies, along with the effective dates and policy/group numbers.
7. Complete the employment status and bank information sections. Indicate your employment status and check all that apply for both yourself and your spouse/partner.
8. Fill in the liquid assets section. If you have liquid assets, provide details regarding the type of asset, the name of the financial institution, and the estimated value.
9. Provide detailed income information for all household earners, including wages from employment, unemployment benefits, Social Security, pension, income assistance, alimony, child support, and any other income sources.
10. Read the certification statement carefully. Ensure that all the information provided is true and correct, and then sign and date the application.
11. Once you have completed the form, review all entries for accuracy, and save changes, download, or print the form as necessary. Share the completed application and any required documents with the appropriate entity outlined in the instructions.

Take the next step towards financial assistance by completing the MN HealthPartners 16491 form online today.