Billing: Patient Financial Assistance - Mayo Clinic Laboratories

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Patient Financial Assistance

Web:	mayocliniclabs.com
Email:	mcl@mayo.edu
Telephone:	800-533-1710
International:	+1 855-379-3115
Values are valid only on day of printing.

Patient Financial Assistance Application

The Mayo Clinic Laboratories’ Patient Financial Assistance Program reduces out-of-pocket costs to patients who qualify based on household income and insurance status.

Patient Financial Assistance Qualification Criteria

Patients who have household incomes up to 3 times the poverty level (see Tier 1 grid below) and also have insurance coverage considered out-of-network with Mayo Clinic Laboratories will pay no more than $200.
Patients who have household incomes above 3 times and up to 6 times the poverty level (see Tier 2 grid below), and also have insurance coverage considered out-of-network with Mayo Clinic Laboratories, will pay no more than $500.
Patients must have an invoice balance greater than $200 to be considered.
Patients may not have insurance coverage considered in-network with Mayo Clinic Laboratories.
Patients may not be enrolled in Medicare, Medicaid, or any other government funded insurance program.

Persons in Family or Household	Number of Persons in Household Tier 1 Patient Household Income (Annual)*	Number of Persons in Household Tier 2 Patient Household Income (Annual)**
1	$45,180	$90,360
2	$61,320	$122,640
3	$77,460	$154,920
4	$93,600	$187,200
5	$109,740	$219,480
6	$125,880	$251,760
7	$142,020	$284,040
8	$158,160	$316,320
Patient Responsibility	$200	$500

Information above is from the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2). Poverty guidelines are subject to change.

To apply for financial assistance, complete the following form.

All fields are required unless specified as optional.

Patient or Responsible Party

First Name

Middle Name (optional)

Last Name

Date of Birth

Phone Number

Patient Account Number

Patient Household Information

Number of Persons in Patient Household

Patient Household Income (annual)

The United States Census Bureau defines a household as all the people who occupy a housing unit. A house, an apartment, other group of rooms, or a single room is regarded as a housing unit when it is occupied or intended for occupancy as separate living quarters. Patient household income is the gross annual income (before taxes) of all persons in the household at the time of application completion.

Certification

By submitting, I certify the following:

I certify that I am not enrolled in Medicare, Medicaid, or other government funded insurance.
I understand and agree that Mayo Clinic Laboratories reserves the right at any time and without notice to modify the application form; to modify or terminate this Program; and to audit the information I have provided on this application by requesting additional documentation including, but not limited to: tax returns and supporting schedules, pay stubs (most recent 3 months), W-2’s or Unemployment Statement.
I understand that completion and submission of this application does not guarantee any balance adjustment for services performed by Mayo Clinic Laboratories. If I do not qualify, I will be notified and invoiced by Mayo Clinic Laboratories.
I certify that the information provided by myself or my legal representative is true and accurate.

If you have questions about your invoice or payment options, contact the Mayo Clinic Laboratories business office at 800-447-6424.