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's Address (Street, City, State and Zip)
Client's Date of Birth
Client's Social Security Number
Client's Insurance (Clients with Medicaid or Medicare do not qualify for financial assistance)
Client Marital Status
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 Name (First, M.I. and Last)
Spouse address (Street, City, State and Zip)
Spouse's Date of Birth
Number of Dependants
Total Monthly Household Income (including social security income):
Household’s value of assets not including primary residence:
Comment below stating your source for paying living expenses, if you are not working
Most recent tax return, including W-2 forms and supporting schedules.
Last two pay stubs.
Written proof of any other income received.
A letter from family/friend stating you are not independently supporting yourself, if you are not working.
A letter from DHS or other agency confirming your financial status, if you are not working.
We require you to apply for Medicaid at
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
Denial letter from Medicaid
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.
I do Acknowledge
I do NOT Acknowledge
Mail Documentation (or hand deliver to any Solvista Health location), or email to
Solvista Health Business Department
3225 Independence Rd
Canon City, CO 81212
Note: Please allow 4 to 6 weeks for processing, once documents are received.
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This form was created inside of Solvista Health.