Financial Assistance Policy/Charity Care
Financial Assistance Program/Charity Care
We have established a financial assistance program to provide a full or partial discount of medical services to patients who meet eligibility standards and are unable to pay. The financial assistance program covers all services provided and billed by Northfield Hospital + Clinics.
How do I qualify for this program?
We determine eligibility by comparing family income and assets to Federal Poverty Guidelines and the guidelines established by Northfield Hospital + Clinics.
If your total family income (before taxes) is less than 200% of Federal Poverty Guidelines, you may qualify for a full discount.
If your total family income (before taxes) is between 200%-300% of Federal Poverty Guidelines, you may qualify for a partial discount.
| Family Size | 100% | 200% | 300% |
| 1 | $15,060 | $30,120 | $45,180 |
| 2 | $20,440 | $40,880 | $61,320 |
| 3 | $25,820 | $51,640 | $77,460 |
| 4 | $31,200 | $62,400 | $93,600 |
| 5 | $36,580 | $73,160 | $109,740 |
| 6 | $41,960 | $83,920 | $125,880 |
| 7 | $47,340 | $94,680 | $142,020 |
| 8 | $52,720 | $105,440 | $158,160 |
You will need to attach your denial from Medical Assistance and include 3 current pay stubs for patient, parent and/or spouse along with your completed application.
How do I apply for Financial Assistance?
If you think that you may qualify for financial assistance and wish to apply, please fill out a financial assistance application below, or contact the Patient Financial Services Department at 507-646-1399. You will be sent an application to complete and return to us.
Once the completed application and all paperwork is returned, NH+C will determine if you qualify for either a full or partial discount on your services based on the information included.
The patient will be notified by either telephone or in writing of the decision made regarding their financial assistance application.
The completed application, proof of denial of Medical Assistance and three pay stubs should be returned to:
Northfield Hospital + Clinics
Patient Financial Services Dept
2000 North Ave
Northfield MN 55057
Financial Assistance Forms