Financial Assistance Application

Financial Assistance Application

Altru provides financial counseling and assistance, to those who meet set criteria, for uninsured and under-insured people of limited means, without regard to race, color, sex, national origin, disability, religion, age, sexual orientation, or gender. Financial assistance may include full or partial assistance write-off or reduced monthly payments. More Information can be found by visiting this link or by calling our HERO team at 701.780.5060.

The Financial Assistance Application must be completed, signed, and returned with all required documents to help us determine the level of availability of financial assistance.

Required Documentation

(Applications returned without required documentation will not be processed)
- A complete copy or your most recent tax return.
- Income verification to include a copy of three (3) most recent pay stubs, unemployment benefits, or social security benefits letter.
- A complete copy of three (3) most recent bank statements from all accounts (to verify expenses}.
- A written explanation describing your need for financial assistance.
- Or a written letter of support why a required document is unavailable/missing
Family Income

Amounts listed in this section of the application should include applicant's and spouse's or significant other's monthly gross income. Income includes earnings, unemployment compensation, worker's compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments survivor benefits, pension or retirement income, interest dividends, rents, royalties, income from estates, trust, education assistance, alimony, child support, assistance from outside the household and other miscellaneous sources. It does not include noncash benefits (such as food stamps and housing subsidies) or capital gains and losses.

The application is incomplete unless it is signed by both you and your spouse/significant other.

Mailing Address:

If unable to complete the online application, please mail application and all supporting documents to:

Altru Health System
P.O. Box 13780
Grand Forks, ND 58208-3780
Date*

MonthDayYear
Date
Patient Name First, Middle, Last*
Birthday*
Altru MRN Number
Account Number(s)

Responsible Party Information
Name First, Middle, Last*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years There
Marital Status*
Home Phone*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Household Size Patient, Spouse, and Dependents
Employment Status*

Full TimePart TimeSelf EmployedUnemployedStudent
Employer Name
Employment Length
Unemployed Date/Length (mm-dd-yyyy)

MonthDayYear
Date
Employer Phone
Please enter a valid phone number.
Are you claimed on another tax return? If yes, provide tax returns of those being claimed*

YesNo
Please upload required documents

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Spouse/Partner Information
Name (First, Middle, Last)
Date of Birth

MonthDayYear
Date
Social Security Number
Home Phone
Cell Phone
Employer Name
Employment Length
Employment Status

Full TimePart TimeUnemployedSelf EmployedStudent
Unemployed Date/Length (mm-dd-yyyy)

MonthDayYear
Date

Bank Accounts
(Not applicable for NHSC Sliding Fee Program)
Total Monthly Income

Family Household Income (Include all family in household or provider support*

	Monthly Income Amount
Self
Spouse/Partner
Alimony
Child Support
Disability
Interest/Dividends
Pension/Retirement
Income from Rental Property

Total Monthly Income *

The information stated in this application is correct to the best of my knowledge. You are authorized to check my credit and employment history and to answer questions about your credit experience with me. By signing this agreement, I am promising to cooperate with Altru Health System staff and provide adequate information in a timely matter to get my bill resolved. Providing any false information will disqualify an applicant from program participation.*
Print First and Last Name
Signature*

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Date*

MonthDayYear
Date
Signature of Spouse/Significant Other

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Date

MonthDayYear
Date
Please attach the following documents (Applications without attachments will not be accepted).
- Tax returns and supporting schedules (most recent year)
- Three (3) most recent pay stubs, unemployment benefits, or social security benefits letter*
- Three (3) most recent bank statements for all accounts*
- Written explanation describing your need for financial assistance*
- Or a written letter of support why a required document is unavailable/missing* *Not applicable for NHSC Sliding Fee Program
File Upload*

Cancelof
Should be Empty:

Financial Assistance Application

Required Documentation

Family Income

Responsible Party Information

Spouse/Partner Information

Bank Accounts

Total Monthly Income