Financial Assistance "*" indicates required fields InstagramThis field is for validation purposes and should be left unchanged.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 a group of two or more people who reside together and who are related by birth, marriage (including legal common law spouse), or adoption. Dependents over the age of 18 will only be considered in the family size calculation if they are listed on the previous year’s tax return.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 5680This field is hidden when viewing the formYearly Rate 15960This field is hidden when viewing the formCalculated % FPLThis field is hidden when viewing the formAnnual Income
