Solvista Health Financial Assistance Application (New Client Packet)

Solvista Health

NOTE: To comply with federal regulations, and in order to give you a discount on our medical services, it is necessary for us to ask some personal questions. You must verify your income at least every year. Family size and annual income will be used to determine your eligibility and calculate your discount.
Solvista Health Financial Assistance Application
First Name
Middle Name
Last Name
Other names
Home Address

Mailing Address

Street Address Line 2

CityState

Zip
Is Home address same as mailing address?
Mailing Address

Mailing Address

Street Address Line 2

CityState

Zip
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date

MonthDayYear

Household Size & Income: List only the people who are supported by the family/household income (for example: yourself, spouse, or children). Do not list roommates or anyone who pays their own living expenses. Please include all income for the people you list. You must also include a copy of a paystub for each member who receives wages, tips, or salary, as proof of income for this section.

Rows	Name	Date of Birth	Relationship	Income Before tax(wages/tips/salary)
1
2
3
4
5
Total

Frequency Paid (Person 1)
Frequency Paid (Person 2)
Frequency Paid (Person 3)
Frequency Paid (Person 4)

Additional Household Income: Please list any other income received by household members. Include income for all people listed in the Household Size section. If multiple members receive the same type of income, list each person. Attach the required proof for each income source listed.

Rows	Name (s)	Income Source	Monthly Amount
Unemployment Compensation-Please attach Award letter or statement
Self-Employment Income-Please attach Prior year income tax return
Worker's Compensation-Please attach Award or determination of benefits letter
SSDI or SSI-Please attach Benefit letter, statement of benefits received, notice of award
Alimony-Please attach Court Decree
Rental Income-Please attach Copy of lease
Trust Fund-Please attach Letter from trustee

Proof of income

Paystubs, award letters, benefit letters, taxes, court decrees, etc.
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Please note that this process could take up to 45 minutes to complete.
Acknowledgement I hereby attest that I can access and view the sliding fee scale and that the information | have provided is true and correct. I understand providing false or misleading information may disqualify me immediately and I may 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.
Name Client Print
Client Signature

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Date

MonthDayYear
Date
Should be Empty: