SpectraPlan Eligibility 2026

SpectraPlan Eligibility 2026

Spectra Health Clinics
Spectra Health offers a sliding fee discount program, known as the SpectraPlan. The SpectraPlan can assist with the cost of care for services at Spectra Health.

The family size and income information collected in this form indicates whether your household may qualify for the discount program at Spectra Health. You can decline to participate in the discount program. Please note refusing is declining ANY possible discount on future services. All discounts are subject to a Nominal Fee.
If eligibility is indicated in this form, a separate application along with income verification is required to determine final approval status.

Spectra Health Social Service Department would be pleased to assist with your SpectraPlan application process. Please call 701-757-2100 ext. 1218 for further assistance.
NOTICE: The SpectraPlan discount program can NOT be applied to reduce any monthly Medicaid recipient liability.
Date

MonthDayYear
Date
Applicant Information

Your name, address, and contact info
Name of financially responsible party:

First NameMiddle Name (Not Required)Last Name
Date of Birth:

MonthDayYear
Social Security Number:
Billing Address:
Street address/house number
City:
State:
Example: ND
Zip Code
example: 58203
Phone Number:
(###) ###-####
Email Address:
example@domain.com
dob print
Household and Income Details
Family Size:
the total number of people in your household
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
Acknowledgement and Signature
Please check ONLY ONE box below:
ARCHIVED Signature
Applicant Signature
Date Signed

MonthDayYear
Date
ARCHIVED Date of Birth

MonthDayYear
Date
sender email
example@example.com
sender name
Should be Empty:

SpectraPlan Eligibility 2026

Applicant Information

Household and Income Details

Acknowledgement and Signature