Request for Financial Assistance

All patients seeking health care services at GO Therapy are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay. This program is designed to provide free or discounted care to those who have no means, or limited means, to pay for their medical services (uninsured or underinsured).

GO Therapy will offer a Sliding Fee Discount Program to all who are unable to pay for their services. GO Therapy  will base program eligibility on a person’s ability to pay and will not discriminate on the basis of an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, gender identity, ability to pay, or whether payment for those services would be made under Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule to determine eligibility.

Above, you can click on “Fill Out Sliding Fee Discount Application” under the Forms section.

What does financial assistance cover? Financial assistance covers medically necessary services, depending upon your eligibility. Financial assistance may not cover all health care costs, including services provided by other organizations.

If you have questions or need help completing this application: You may obtain help for any reason, including disability and language assistance by contacting Client Support at info@gotherapymn.com or via phone: 507-934-3573, Monday-Friday, 8:00 am to 5:00 pm

In order for your application to be processed, you must provide:

• Information about your family (Fill in the number of family members in your household (family includes people related by birth, marriage, or adoption who live in the home).

• Information about your family’s net monthly income (all income, from any source, after taxes and deductions) 

• Declare assets (as listed on financial assistance application form)

• Attach additional information if needed

• Sign and date financial assistance form

**Income Source Verification Required**
Please submit with your application copies of the following documents:

• 3 months of employment pay stubs

• Recent filed tax return for all family members

• Proof of any other income source as listed on financial assistance application form

Mail completed application with all documentation to the following address (be sure to keep a copy for yourself): GO Therapy 830 Sunrise Dr. Suite B, St. Peter, MN 56082
To submit your completed application in person: Take the form to our clinic and hand to Office Manager, Abbee or Kari at the front desk.