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*All fields required unless marked optional

Contact Reason

Change of address

Question about your statement

Provide insurance information

Compliment or complaint about care or services

Request an itemized payment receipt

Financial Assistance Application

Other

Contact Reason

Change of address

Question about your statement

Provide insurance information

Compliment or complaint about care or services

Request an itemized payment receipt

Probate Inquiry

Financial Assistance Application

Other

Do you need to start a new application or update an existing application?

Start a New Application

Update an Existing Application

*To track the status of your financial assistance application, please log in to your online account to review your application.

Please add additional instructions for your request:

Are you contacting us about your account?

Yes

No

Account information

Your name

Your address

Your city

Your state

Your zipcode

Your date of birth

Your account number (optional)

Please note, each patient’s privacy is important to us. If you are requesting information on behalf of an adult patient, please be aware that we will not be able to give you account information without the patient’s verbal or written consent. If the patient is under age 18 and you are the legal guardian, consent is not usually required. For additional information, please refer to our Legal notices and Notice of Privacy Practices.

Your name

Patient name

Patient address

Patient city

Patient state

Patient zipcode

Patient date of birth

Patient account number (optional)

Change of address

Address currently on file with HealthPartners

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Previous Address

Previous City

Previous State

Previous Zip Code

New address

---

New Address

New City

New State

New Zip Code

Is the new address permanent?

Yes

No

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

Statement question

Preferred method of follow-up contact:

Email

Telephone

Postal mail

Email address

Daytime telephone number

Mailing address(only if different from above)

Name on the statement

Would you like us to send you a billing statement showing a detailed itemization of services provided?

Yes

No

Which billing statement(s) would you like us to send?

I would like details for the balance due on a specific date

I would like details for all balances due on my account with HealthPartners

I would like details for any balance placed with a collection agency

Statement date:

Request types

Electronic delivery

Paper Copy (for fee of $6.50 plus postage)

If you request a paper copy, you will receive your detailed bill along with an invoice for the fee of $6.50 plus postage.

Please provide as much information as possible to better assist you. Helpful information may include: Invoice number, account number, date of service, clinic location, etc.

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

Provide Insurance Information

What type of insurance?

Medical insurance

Worker's compensation

Motor vehicle insurance

Medical insurance questionnaire

Insurance company name:

Policy holder (subscriber):

Insurance ID number:

Group number (optional):

Insurance company phone number (optional):

Address to send claims (optional):

Coverage start date (optional):

Coverage end date (optional):

Which insurance is this?

Primary insurance

Secondary insurance

Tertiary insurance

Do you have another insurance plan?

Yes

No

Medical insurance questionnaire

Insurance company name:

Policy holder (subscriber):

Insurance ID number:

Group number (optional):

Insurance company phone number (optional):

Address to send claims (optional):

Coverage start date (optional):

Coverage end date (optional):

Which insurance is this?

Primary insurance

Secondary insurance

Tertiary insurance

Worker's Compensation Insurance

Insurance company name:

Insurance address:

Claim number:

Date of injury

Place of injury (optional):

Time of injury (optional):

Body part injured (optional):

Contact person/claims adjuster (optional):

Contact person telephone number (optional):

Employer name (optional):

Employer address (optional):

Employer city (optional):

Employer state (optional):

Employer zip code (optional):

Motor Vehicle Insurance

Insurance company name:

Insurance address:

Claim number:

Date of injury:

Place of injury (optional):

Time of injury (optional):

Body part injured (optional):

Contact person/claims adjuster (optional):

Contact person telephone number (optional):

Please add additional instructions for your request: (optional)

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

Compliments and Complaints

Preferred Method of follow-up contact

Email

Telephone

Postal Mail

Email

Daytime telephone number

Mailing address(only if different from above)

By providing us as much information about your experience as possible, we can ensure that your feedback is directed to the appropriate clinic or department.

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Date of service or incident:

Clinic location: (optional)

If name of HP employee/medical provider is known, please provide: (optional)

Position of the employee/medical provider. (optional, examples include: scheduler, check-in staff, nurse/assistant, care/medical provider, clinic supervisor, or other)

Please describe your question, comment or concern (optional)

If you have a complaint, please share your preferred resolution (optional)

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

Request an Itemized Receipt

Preferred method of follow-up contact:

Email

Telephone

Postal mail

Email address:

Daytime telephone number:

Postal mail:

Request types:

Electronic delivery

Paper Copy (for fee of $6.50 plus postage)

If you request a paper copy, you will receive your detailed bill along with an invoice for the fee of $6.50 plus postage.

Itemized receipt by:

Service date

Payment date

Date Range

---

Start date:

End Date:

Please add additional instructions for your request: (optional)

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

Account information

Your name

Your address

Your city

Your state

Your Zipcode

Your date of birth

Your account number (optional)

Probate Case Information

Date of death

Probate court case number

Please add additional instructions or information to assist us in completing your request (optional):

Are you contacting us about your account?

Yes

No

Account Information

Your name

Your address

Your city

Your state

Your zipcode

Your date of birth

Your account number (optional)

Probate Case Information

Data of death

Probate court case number

Please add additional instructions or information to assist us in completing your request (optional):

Preferred method of follow-up contact:

Email

Telephone

Postal mail

Email address:

Daytime telephone number:

Mailing address (only if different from above):

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

Apply online via your myHealthPartners account:

Use your Online Patient Services by signing on to your myHealthPartners account, choose the account you want to apply for financial assistance, and complete the application.

Apply Online without an account:

If you do not have a myHealthPartners account, complete the Financial assistance application online.

Preferred Method of Follow-up contact:

Email

Telephone

Postal mail

Email address:

Daytime telephone number:

Mailing address:

Please provide as much information as possible to better assist you. Helpful information may include: Invoice number, account number, date of service, clinic location, etc.

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

Other

Preferred method of follow-up contact:

Email

Telephone

Postal mail

Email address:

Daytime telephone number:

Mailing address(only if different from above)

Please provide as much information as possible to better assist you. Helpful information may include: invoice number, account number, date of service, clinic location, etc.

Please attach a copy of your insurance card(s) or the appropriate documents (optional):

Attach

Attach

Attach

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