How to Fill Out and Submit the Sanford Financial Assistance Form

The Sanford financial assistance application is a two-page form that asks a non-profit hospital to forgive or reduce your bill for emergency or medically necessary care based on your household income. If your household earns at or below 225% of the Federal Poverty Level, your patient balance can be written off entirely. Between 226% and 375% of the poverty level, you qualify for a sliding-scale discount instead.¹ A written decision arrives within 30 days of submission.²

Who Qualifies

Eligibility turns on your household size and gross income measured against the Federal Poverty Guidelines that the Department of Health and Human Services publishes each year. There are two tiers. Income at or below 225% of the Federal Poverty Level means full forgiveness of your patient-due balance. Income from 226% to 375% means a partial discount, with the discount percentage decreasing as income rises through sub-brackets of 226–275%, 276–325%, and 326–375%.¹ The exact discount percentages for each sub-bracket are published in Sanford’s sliding discount schedule, available from Patient Financial Services or the billing section of the Sanford Health website.

Gross income means household earnings before taxes or deductions: wages, Social Security, unemployment, pension income, and similar sources. Household size includes everyone claimed on your tax return. The program applies to charges for emergency and medically necessary care at a Sanford facility, billed through its centralized Patient Financial Services.¹ Cosmetic and elective procedures that are not medically necessary are not covered.

2026 Income Ceilings by Household Size

The 2026 Federal Poverty Guidelines set the baseline. The approximate annual ceilings for the 48 contiguous states (Alaska and Hawaii use higher figures) are:³

1 person: 100% FPL = $15,960; full forgiveness ceiling (225%) ≈ $35,910; partial discount ceiling (375%) ≈ $59,850
2 people: 100% FPL = $21,640; full forgiveness ≈ $48,690; partial discount ≈ $81,150
3 people: 100% FPL = $27,320; full forgiveness ≈ $61,470; partial discount ≈ $102,450
4 people: 100% FPL = $33,000; full forgiveness ≈ $74,250; partial discount ≈ $123,750

For each additional household member beyond four, add roughly $5,680 to the base figure. For households larger than eight, Sanford’s Patient Financial Services can help confirm eligibility.

Documents to Gather Before You Start

Sanford will not process an incomplete application, so pull everything together before you open the form. Three categories of paperwork are required:⁴

Your most recent federal 1040 return with all applicable schedules. If you did not file, substitute a Social Security award letter or request a Verification of Non-Filing letter from the IRS at (800) 908-9946.²
The two most recent pay stubs for every wage earner in the household.⁴
A current bank or investment statement showing transaction data and balances.¹

If your care was delivered at a National Health Service Corps (NHSC) facility inside the Sanford system, a separate NHSC Assistance Application applies. It asks for the same tax return and pay stubs plus a copy of your insurance card, and does not require bank statements.⁴

Filling Out the Form

The application is a two-page PDF. Download it from the financial assistance section of sanfordhealth.org or pick it up at any Sanford hospital business office.⁴ Print and complete by hand, or type into the PDF fields.

The first section covers personal information: name, date of birth, address, and contact details. The next section asks about employment; list every employed member of the household and their employer. Then enter each person living in the household and their ages. That count sets which row of the Federal Poverty Guidelines Sanford will measure you against.

The income section is where most people slow down. Transfer the totals from your pay stubs and tax return into the income fields on the form. The numbers you write on the application should match the numbers on the documents you attach. A mismatch between reported income and the figures on your 1040 or pay stubs is the most common reason applications come back for clarification. Fill in every field; blank lines can flag the form as incomplete and add weeks to the review.

Sign and date the form at the bottom. The certification states that the information and supporting documents are “true and correct to the best of my knowledge.”² Check that the names on your attached documents match the name on the application exactly. A maiden name on a tax return paired with a married name on the form can prompt a documentation request and slow the process.

How to Submit

Three channels are available:

Mail the application and all supporting documents to Sanford Health, PO Box 2010, Sioux Falls, SD. The full address is on the form instructions.
Fax the completed packet to (800) 544-5967.
Hand-deliver it to the business office of the Sanford hospital where you received care.

Keep copies of everything. If you mail the packet, consider certified mail or a tracked service so you have proof of delivery. For questions about submission, or to confirm whether a local facility accepts walk-ins, call Sanford Patient Financial Services at (877) 629-2999.²

What Happens After You Submit

Sanford reviews the application and mails a written determination within 30 days of receiving it.² The letter will say one of three things: your balance has been forgiven in full, a partial discount has been applied and a reduced balance is owed, or your application was denied with the reasons noted.

Approved full forgiveness drops the outstanding balance to zero, and an updated statement follows showing no amount due. For partial discounts, the letter states the discount percentage, and a revised statement arrives showing the new balance. If something is missing, the notice explains what documentation to send so you can resubmit.

Protections While Your Application Is Pending

Under IRS regulations, non-profit hospitals must accept financial assistance applications for at least 240 days from the date they send you the first post-discharge billing statement. A separate 120-day notification period runs at the start of that window, during which the hospital must tell you that financial assistance is available and explain how to apply.⁵ Submit an incomplete application inside that window and Sanford must tell you what is missing and give you a reasonable chance to complete it.

Federal law also bars tax-exempt hospitals from pursuing extraordinary collection measures such as lawsuits, wage garnishment, or liens on a home before making reasonable efforts to determine whether a patient qualifies for financial assistance.⁶ Sanford’s own policy commits to the same restraint.¹ A bill that has been sitting on your counter for months does not disqualify you from applying.

If You Are Denied

A denial can be appealed. If your situation has changed since you first applied, whether through job loss, a new medical expense, or reduced hours, submit an appeal within 30 days of the date on the determination letter.² Include documentation that reflects the change: a termination letter, newer bank statements, or a revised income summary.

Call Sanford Patient Financial Services at (877) 629-2999 to discuss your account, ask about the denial, or begin an appeal. Having your account number and the determination letter in front of you shortens the call. Even past the 30-day window, ask whether reapplying with new documentation is an option when your circumstances have shifted significantly.

1
Sanford Health. Summary of Financial Assistance
2
Sanford Health. Financial Assistance Application
3
HHS ASPE. 2026 Poverty Guidelines
4
Sanford Health. Financial Assistance Policy
5
Internal Revenue Service. Billing and Collections – Section 501(r)(6)
6
Office of the Law Revision Counsel. 26 USC 501 – Exemption From Tax on Corporations, Certain Trusts, Etc