• SpectraPlan Application

    SpectraPlan Application

  • Date
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  • Applicant Information

    This form should be completed by a household's financially responsible party (guarantor). Proof of income is required within thirty (30) days of submitting this application.
  • Date of Birth*
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  •  -

  • Income Information

  • Please indicate which type of income your household receives AND provide proof of all household income within 30 days of application.

     

    Not sure what to provide for proof of income? Answer the below questions and Accepted documentation will pop up when you select "yes". 

  • Employment Income*

  • Accepted Documentation:

    • Most recent Federal Income tax return
    • Last (2) Consecutive paystub
    • Letter from employer validating hours/wages
  • Immigration Income*

  • Accepted Documentation:

    • Immigration forms I20 or J1
    • Refugee Cash Assistance
  • Self-Employment Income*

  • Accepted Documentation:

    • Current Income Statement
    • Most recent federal income tax return
  • Public Assistance - TANF/MFIP*

  • Accepted Documentation:

    • Award Letter(s) listing amount received (current year)
  • Social Security Benefits*

  • Accepted Documentation:

    • Award Letter(s) listing amount received (current year)
  • Unemployment Compensation*

  • Accepted Documentation:

    • Benefit Award Letter (current year)
  • Workers' Compensation*

  • Accepted Documentation:

    • Benefit Award Letter (current year)
  • Retirement/Pension*

  • Accepted Documentation:

    • Plan administrator documentation stating monthly
      benefit amount (current year)
  • No Income?*

  • Accepted Documentation:

    •  Letter from previous employer documenting last day of
      employment
    •  Form/Letter Verifying Zero Income From
      Agency/Caseworker (agency letterhead required)
    • Tax Form 4506t
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  • Household Information

  • Complete table for applicant and all other individuals within the household regardless of insurance status. Note: DO NOT list individuals for which the responsible party is not FINANCIALLY responsible.

  • Date of Birth*
     - -
  • Receives Income*
  • Do you wish to add more family members?*
  • Date of Birth
     - -
  • Receives Income
  • Do you wish to add more family members?
  • Date of Birth
     - -
  • Receives Income
  • Do you wish to add more family members?
  • Date of Birth
     - -
  • Receives Income
  • Do you wish to add more family members?
  • Date of Birth
     - -
  • Receives Income
  • Do you wish to add more family members?
  • Date of Birth
     - -
  • Receives Income
  • Do you wish to add more family members?
  • Date of Birth
     - -
  • Receives Income
  • Would you like follow up from Spectra Health Social Services to discuss insurance coverage options?

  • If you have questions about this form or the SpectraPlan, please contact Spectra Health Social Services at 701-757-2100, extension 1218.

    PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING/SUBMITTING THIS APPLICATION.

  • Please note the SpectraPlan discount program can NOT be applied to reduce any monthly Medicaid recipient liability for those patients for whom this applies.

  • *
    Financial Responsibility: I understand that there may be a nominal fee of $30 (Dental), $20 (Primary Medical Care - Including Chiropractic Care), or $3 (Behavioral Health) that is due at the time of EACH visit. Additionally, I understand that any services processed at Spectra Health may qualify for the SpectraPlan Discount; however, any services that are sent to an outside facility will be my personal financial responsibility.

    As the above-named head of household (guarantor), I accept financial responsibility for everyone listed on this application. 

  • *
    Proof of income is required to process your application. Within 30 days, I agree to provide Spectra Health with all mandatory information, for all requested individuals, to determine discount qualification. Failure to provide requested documentation (within 30 days) may prevent any eligible discount.

  • Applicants who do NOT receive income must provide approved documentation (see accepted documentation table (page1) for examples).

    By signing below, I agree that Spectra Health staff may contact employers of all individuals working within the household and/or authorized agencies to confirm provided income information. For purposes of determining SpectraPlan eligibility, I authorize Spectra Health to contact the people listed in my household on this application and share with them the financial information provided in this application. I understand that I will need to reapply for the SpectraPlan program annually. Any changes to household size, income, or insurance status requires notification to Spectra Health within 30 days. Failure to provide updated information may result in termination of SpectraPlan eligibility.

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