FA Application – Sleepy Eye Medical Center Financial Assistance

Online Application

"*" indicates required fields

Welcome to your Sleepy Eye Medical Center online financial assistance application!

In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household:
Most recent pay stubs covering the last two months
Two most recent bank statements for checking and savings accounts
Most recent tax return
After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you.

Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application.

Including yourself, what is the total number of immediate family members who live in your home?*

Additional Household Member 1 – Name*

First Last

Additional Household Member 1 – Date of Birth*

Additional Household Member 1 – Relationship to Applicant*

Additional Household Member 2 – Name*

First Last

Additional Household Member 2 – Date of Birth*

Additional Household Member 2 – Relationship to Applicant*

Additional Household Member 3 – Name*

First Last

Additional Household Member 3 – Date of Birth*

Additional Household Member 3 – Relationship to Applicant*

Additional Household Member 4 – Name*

First Last

Additional Household Member 4 – Date of Birth*

Additional Household Member 4 – Relationship to Applicant*

Additional Household Member 5 – Name*

First Last

Additional Household Member 5 – Date of Birth*

Additional Household Member 5 – Relationship to Applicant*

Additional Household Member 6 – Name*

First Last

Additional Household Member 6 – Date of Birth*

Additional Household Member 6 – Relationship to Applicant*

Additional Household Member 7 – Name*

First Last

Additional Household Member 7 – Date of Birth*

Additional Household Member 7 – Relationship to Applicant*