Perham Health is dedicated to providing quality health care to our patients. We realize that payment of those services may be a financial hardship for you at this time. Therefore, we are offering you the opportunity to apply for financial assistance with our health system.
On the next page, you will find a worksheet/application that demonstrates your financial condition. You must complete this document in full to receive consideration for our financial assistance program. If your financial situation meets the criteria set forth by Perham Health, part or all of your account balance may be forgiven.
In order to process this application we require:
We realize that your income from previous tax records may not adequately reflect your current circumstances. If so, please attach a brief note that describes your current financial situation.
Once we have reviewed your application, we will notify you of our decision in writing within 30 days of receipt. If you wish to discuss your account or have any questions, please contact us at (218) 347-1353. Our business hours are Monday - Friday 8am – 4:30pm.
To Minnesota residents receiving service at Perham Health: If you feel that your concerns have not been addressed, please contact our Patient Financial Services Department at (218) 347-4500 first and allow us the opportunity to try and address your concerns. If you continue to have concerns that have not been addressed, you may contact the MN Attorney General's Office at (651) 296-3353 or (800) 657-3787.
Time at Present Address:
How Long Employed:
By signing below I certify that the information and statements contained in this Application for Financial Assistance and the documentation which I
submit are accurate, true and correct to the best of my knowledge.
I understand that Perham Health may make reasonable requests for additional information and verification if necessary. I
understand that the information and statements I have provided will be kept confidential by Perham Health.
I understand that the completion of this application will allow Perham Health to consider my circumstances. I
understand Perham Health makes no representations that financial assistance is guaranteed.
I/We hereby certify the above information is correct and voluntarily authorize you to obtain credit information relative to me/us.