SpectraPlan Eligibility 2026

SpectraPlan Eligibility 2026
Date*

MonthDayYear
Date
- Name*
  
  First NameM.I.Last Name
- Billing Address*
- City*
- State*
- Zip Code*
- Phone Number*
- Social Security Number
- Date of Birth*
  
  MonthDayYear
  Date
- Email Address*
  example@example.com
- 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 2026 SpectraPlan Discount Program eligibility (please note that you do not have to do anything with this chart, it is only for reference):
- Spectra Health offers a sliding fee discount program, known as the SpectraPlan. Please note, a separate application and income verification is required for discount program determination. The SpectraPlan can assist with the cost of care for services at Spectra Health.
  
  The family size and income information collected above 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.
- I WANT to apply for the SpectraPlan. I WANT to be contacted by Spectra Health staff to discuss completing a full SpectraPlan application and providing income verification.I DO NOT want to apply for the SpectraPlan. I do not want/need any discount on future services I receive at Spectra Health. I understand I can apply for the SpectraPlan at any time in the future if needed.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.
- 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.
  
  Please note the SpectraPlan discount program can NOT be applied to reduce any monthly Medicaid recipient liability for those patients for whom this
  applies.
- Should be Empty: