SpectraPlan Eligibility 2024

Family Size & Income
Family Size*
Income for Family Size 1
Income for Family Size 2
Income for Family Size 3
Income for Family Size 4
Income for Family Size 5
Income for Family Size 6
Income for Family Size 7
Income for Family Size 8
Income for Family Size 9
Income for Family Size 10
Below is a chart reflecting our 2023 SpectraPlan Discount Program eligibility (please note that you do not have to do anything with this chart, it is only for reference):
Please check ONLY ONE box below:*

I WANT to be contacted by Spectra Health to complete a full SpectraPlan application based on my eligibility information.I DO NOT want to be contacted by Spectra Health to complete a full SpectraPlan application. In understand I can reapply for the SpectraPlan at any time. Common reasons for not participating in the SpectraPlan are:• A third-party agency is responsible for patient payment.• You are not eligible to participate due to income.• You are not interested in participating but can reapply at any time.

Signature
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
If eligibility is indicated above, please note a full application and income verification is required to determine approval, Spectra Health Social Service Department would be pleased to assist with the full SpectraPlan application process. Please schedule an appointment with registration or call 701-757-2100 for further assistance.
Should be Empty: