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
YesNo
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

Note to comply with federal regulations, in order to give yoi a discount on our medical services,it is necessary for us to ask some personal questions. You must verify your income at least evrey year. Family size and annual income will be used to determine your eligibility and calculate your discount.

Household Income

Rows	Amount $	Frequency (Type one: Weekly, Monthly, Yearly)	Employer:
You
Spouse
Children
Other
Total

Other income

Proof of income

Paystubs, award letters, benefit letters, taxes, court decrees, etc.
Cancelof
Colorado PEAK is the place to apply for Medicaid benefits online!

Interested? Apply Here

Please note that this process could take up to 45 minutes to complete.
NOTE: To comply with federal regulations, 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.
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.
Date*

MonthDayYear
Date
Name Client Print*
Client Signature*

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