Financial Assistance Program

Our financial assistance program helps qualified patients access emergency services and medically necessary care when they need help paying for these services.

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Our Policy

North Memorial Health’s financial assistance policy provides financial assistance (charity care) to low-income, uninsured, or underinsured individuals who need help paying for all or part of their medical care.

Download Financial Assistance Policy (FAP)

Download Financial Assistance Policy Plain Language Summary (PLS)

North Memorial Health patients are eligible for North Memorial Health financial assistance when their Family Income is at or below 300% of the Federal Poverty Level (FPL) income guidelines.

All Policy Requirements outlined below.

Chart outlining all policy requirements. For a household/family size of 1, 200% is $29,160and 300% is $43,740. For a household/family size of 2, 200% is $39,440and 300% is $59,160. For a household/family size of 3, 200% is $49,720and 300% is $74,580. For a household/family size of 4, 200% is $60,000and 300% is $90,000. For a household/family size of 5, 200% is $70,280 and 300% is $105,420. For a household/family size of 6, 200% is $80,560 and 300% is $120,840. For a household/family size of 7, 200% is $90,840 and 300% is $136,260. For a household/family size of 8, 200% is $101,120and 300% is $151,680. For a household/family size of 9, 200% is $111,400and 300% is $167,100. For a household/family size of 10, 200% is $121,680and 300% is $182,520. For a household/family size of 11, 200% is $131,960and 300% is $197,940. For a household/family size of 12, 200% is $142,240 and 300% is $213,360. For a household/family size of 13, 200% is $152,520 and 300% is $228,780. For a household/family size of 14, 200% is $162,800 and 300% is $244,200. For a household/family size of 15, 200% is $173,080 and 300% is $259,620.

Who is eligible for financial assistance and what are the requirements?

Patients who are eligible for North Memorial Health financial assistance will not be charged more than Amounts Generally Billed (AGB) by North Memorial Health for emergency or other medically necessary care to patients with insurance (AGB, as defined by IRS Section 501(r)).

  • You may be eligible for a 100% discount if your Family Income is at or below 200% of the Federal Poverty Level income guidelines.
  • You may be eligible for an Amounts Generally Billed (AGB) discount if your Family Income is at or below 300% of the Federal Poverty Level income guidelines.
  • If your verified Family Income is at or below 300% of the Federal Poverty Level and your medical bills exceed 25% of your Family Income you may also apply for a catastrophic care discount. This program is limited to one episode of care, which includes subsequent treatment or services related to that same episode of care, or a series of ongoing medically necessary services intended to treat a specific diagnosis.
  • Patients whose Family Income is at or below 200% of the FPL with Liquid Assets that exceed $20,000. will be eligible for 100% discount under this policy provided the patient provides payment to North Memorial Health to reduce their Liquid Assets to $20,000. The amount paid by the North Memorial Health patient will not exceed the Amounts Generally Billed. The patient may receive the AGB discount if they choose not to provide payment to North Memorial Health and reduce their Liquid Assets to $20,000.
  • Patients who are provided emergency medical and medically necessary services by North Memorial Health are required to have a claim submitted to the insurance carrier for payment or denial of payment prior to determining the amount eligible for a charity care discount. Patient responsibility after insurance payments will not exceed the Amounts Generally Billed.
  • Patients who may be eligible for alternative sources of payment, such as Medical Assistance, may be required to apply for such programs, prior to financial assistance eligibility determination. A financial assistance application must be completed to determine eligibility for these discounts. Patients should consult with a financial counselor located at the following location to determine eligibility and for assistance with applying for financial assistance:
    • North Memorial Health – Robbinsdale Hospital – Financial Assistance
      3300 Oakdale Avenue North
      Robbinsdale, MN 55422
    • Call: 763-581-0911 or 833-494-2900
  • North Memorial Health participates in Medicare Partners. For this program, North Memorial Health partners with Senior Community Services to waive clinic co-insurance and deductibles for patients who are members of Medicare Partners. Eligibility for this program is determined by Senior Community Partners.
  • North Memorial Health also offers an Uninsured Discount to patients who are not eligible for financial assistance and whose annual income is less than $125,000. If you need additional information on North Memorial Health’s uninsured discount, please call 763-581-0911 or 833-494-2900.

Application Process

How to Apply

Step 1: Fill out the Application
The policy and application are available without charge and can be accessed in any of the following ways:

  1. Download Financial Assistance Application
    English (PDF)
    Spanish (PDF)
    Hmong (PDF)
    Russian (PDF)
    Somali (PDF)
    Vietnamese (PDF)
  2. Download Financial Assistance Application Shelter Statement
    English (PDF)
    Spanish (PDF)
    Hmong (PDF)
    Russian (PDF)
    Somali (PDF)
    Vietnamese (PDF)
  3. Send mailing request to:
    North Memorial Health – Robbinsdale Hospital – Financial Assistance
    3300 Oakdale Avenue North
    Robbinsdale, MN 55422
  4. Call: 763-581-0911 or 833-494-2900
  5. Request at one of the following locations
    • North Memorial Health – Robbinsdale Hospital Registration Department
    • North Memorial Health – Maple Grove Hospital Registration Department
    • North Memorial Health – Financial Assistance, 3500 France Avenue North, Suite 106, Robbinsdale, MN 55422;
    • North Memorial Health Ambulance, 4501 68th Avenue North, Brooklyn Center, MN 55429.

Step 2: Submit Application
Completed applications including all required information and documentation should be submitted to one of the locations above or mailed to:

North Memorial Health – Robbinsdale Hospital – Financial Assistance
3300 Oakdale Avenue North
Robbinsdale, MN 55422

We will promptly review submitted applications with supporting documentation and notify you of financial assistance eligibility in writing within 30 days of receipt of a complete application.

We will not consider incomplete applications, but will notify applicants by phone or mail of an incomplete application and provide you an opportunity to send in the missing documentation or information within 30 days from the date of notification.

Program Coverage

North Memorial Health’s Financial Assistance Policy applies to emergency and medically necessary services provided by North Memorial Health hospital and clinic facilities within the North Memorial Health system, including both facility and professional services offered by North –  Robbinsdale Hospital and North –  Maple Grove Hospital, North Memorial Health hospice services, and North Memorial Health emergency transportation services.

Refer to North Memorial Health’s Financial Assistance Policy for additional information on covered and non-covered services.

Need Help?

For help or questions about the application process, call 763-581-0911 or 833-494-2900 and ask to speak to a North Memorial Health financial counselor.