Solvista Health Financial Assistance Application
Disclaimer: When you click “SUBMIT,” this form and its contents will be sent electronically to Solvista Health. This information will be stored securely to protect your confidentiality. If you prefer, you have the choice to print this form and mail it or hand deliver it to Solvista Health.
Client/Guarantor
Client's Name *
Your answer
Client's Address (Street, City, State and Zip) *
Your answer
Client's Date of Birth *
MM
/
DD
/
YYYY
Client's Social Security Number *
Your answer
Client's Insurance (Clients with Medicaid or Medicare do not qualify for financial assistance) *
Your answer
Client Marital Status *
NOTE:
If you are married, your spouse’s financial information and signature is required in order
to process your application. If you are between 15 and 18, and are seeking services for yourself independently, you only need to provide information for yourself, not your household.
Spouse's Information
Spouse Name (First, M.I. and Last)
Your answer
Spouse address (Street, City, State and Zip)
Your answer
Spouse's Date of Birth
MM
/
DD
/
YYYY
Household Information
Number of Dependants *
Your answer
Total Monthly Household Income (including social security income): *
Your answer
Household’s value of assets not including primary residence:
Your answer
Comment below stating your source for paying living expenses, if you are not working
Your answer
Additional Comments
Your answer
Documentation
Medicaid
We require you to apply for Medicaid at https://coloradopeak.secure.force.com or your local Department of Human Services office. If you need help filling out the forms for your Medicaid application, please call 719-275-2351 and ask for the Client and Family Advocate. If you do not get approved for Medicaid we requires a denial letter in order to go forward with the Financial Assistance Application.


Medicaid Denial Letter
Acknowledgement
Acknowledgement - I acknowledge that the above information is true and accurate to the best of my knowledge. I give Solvista Health permission to verify information I gave on this form. I also authorize Solvista Health to request a consumer credit report, if needed to verify my income.

In the case of willful fraud by misreporting income, living conditions, dependents, or financial condition will face possible restriction for participation in the program for one calendar year, from the time of discovery of fraudulent activity.
Please Select *
Mailing instructions
Mail Documentation (or hand deliver to any Solvista Health location), or email to insuranceverification@solvistahealth.org:

Solvista Health Business Department
3225 Independence Rd
Canon City, CO 81212
719-276-5475
Note: Please allow 4 to 6 weeks for processing, once documents are received.
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