Financial Assistance "*" indicates required fields Thanks for using our Eligibility Checker for Financial Assistance! Answer the following questions to see if you may be eligible for a discount on your Sleepy Eye Medical Center bills.Name* First Last Date of BirthDo you have health insurance?* Yes No Including yourself, how many people are in your immediate family?*“Family” is defined as the applicant, the applicant’s spouse, and all of the applicant’s children under 18 (natural or adoptive) who live in the applicant’s home.Please enter a number from 1 to 10.What is your estimated gross MONTHLY household income?*This is current household monthly income before taxes.Please enter a number from 0 to 1000000.This field is hidden when viewing the formPhone # For Text (Optional)This field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formFamily Additional Total 5380This field is hidden when viewing the formYearly Rate 15060This field is hidden when viewing the formCalculated % FPLThis field is hidden when viewing the formAnnual IncomeCommentsThis field is for validation purposes and should be left unchanged.
