Solvista Health Financial Assistance Application (New Client Packet)

If you do not have insurance or your insurance does not cover your behavioral health services, complete this form to apply for financial assistance. To comply with federal regulations, it is necessary for us to ask some personal questions. Household/ family size and annual income will be used to determine your eligibility and calculate your discount. Please include proof of income for each item with this application. If your income or the number of people in your family/ household changes during your care, you may ask for a review of your eligibility. For support, contact our Client Accounts Representative team at 719-345-6255 or at clientaccounts@solvistahealth.org. Turn your application in to one of our office locations or clientaccounts@solvistahealth.org.

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?*

YesNo

Mailing Address

Street Address Line 2

CityState

Zip

Home Phone Number*

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

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.

Household Size & Income: TOTAL

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.

Please use this table to identify which proof of income you will need to upload in the box below

Income Source	Proof of Income Source
Unemployment Compensation	Award Letter or Statement
Self-Employment Income	Prior year income tax return
Worker's Compensation	Award or determination of benefits letter
SSDI or SSI	Benefit letter, statement of benefits received, notice of award
Alimony	Court Decree
Rental Income	Copy of lease
Trust Fund	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.

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 I 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 I can request a new evaluation if my circumstances change.

Do you have a Primary Care Doctor?*

YesNo

Name Print*

Date*

Date

Signature*