Solvista Health Financial Assistance Application

Solvista Health Financial Assistance Application
Client Name - First, Middle, Last*
Date of birth*

MonthDayYear
Date
Address - Street, City, State, Zip Code*
Phone number*
Email
Number of individuals living in household not including yourself)*
Yearly household Income (combined, including spouse, children, other)*
I hereby attest that I can access and view the sliding fee scale and that the information I have provided is true and correct. I understand that providing false or misleading information may disqualify me immediately and cause me to become financially responsible. I agree to work with Solvista to provide any additional information to help make a determination. I understand that any assistance provided is only available for one year or when my circumstances change, whichever occurs sooner.*

I acknowledge
I hereby attest that I have submitted one of the following documents to Solvista Health via email - billing@solvistahealth.org - Most recent tax return, including W-2 forms and supporting schedules, Last two pay stubs, Written proof of any other income received, A letter self-reporting income, A letter from DHS or other agency confirming your financial status, if you are not working.

I hereby attest that I have the choice to print this form and mail it or hand deliver it to Solvista Health in lieu of electronic submission.

Mail Documentation (or hand deliver to any Solvista Health location), or email to billing@solvistahealth.org :

Solvista Health Business Department
3225 Independence Rd
Canon City, CO 81212
719-276-5475

Note: Please allow 1-2 weeks for processing, once documents are received.
I acknowledge
Signature*
Date signed*

MonthDayYear
Date
Should be Empty: