• SpectraPlan Application

    Spectra Health Clinics

  • If you have questions about how to complete this form or the SpectraPlan in general, please feel free to contact Spectra Health Social Services at:

    • Phone: 701-757-2100 ext. 1218
    • Email: socialservices@spectrahealth.org
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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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  • dob print*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Income Details

  • Please indicate which type of income your household receives.  You'll need to provide proof of all income sources within thirty (30) days of submitting your application.  You can upload proof of income while completing this form, or use the Upload Income Verification form, also available on spectrahealth.org.

     

    Not sure what to provide for proof of income?

    Answer the questions below and accepted documentation types will display if you select "Yes". 

  • Employment Income*

  • Accepted Documentation:

    • Most recent Federal Income tax return
    • Last (2) consecutive paystubs
    • 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 4506-T
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  • Household Details

  • Complete the following for Responsible Party (guarantor) and all other individuals within the household for whom the guarantor is fiancially responsible. 

  • Date of Birth*
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  • Receives Income*
  • Do you wish to add more family members?*
  • Date of Birth:*
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  • print Date of Birth 1*
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  • Receives Income*
  • Do you wish to add more family members?*
  • Date of Birth:*
     / /
  • print Date of Birth 2*
     / /
  • Receives Income*
  • Do you wish to add more family members?*
  • Date of Birth:*
     / /
  • print Date of Birth 3*
     - -
  • Receives Income*
  • Do you wish to add more family members?*
  • Date of Birth:*
     / /
  • print Date of Birth 4 *
     - -
  • Receives Income*
  • Do you wish to add more family members?*
  • Date of Birth:*
     / /
  • print Date of Birth 5*
     / /
  • Receives Income*
  • Do you wish to add more family members?*
  • Date of Birth:*
     / /
  • print Date of Birth 6*
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  • Receives Income*
  • Would you like follow up from Spectra Health Social Services to discuss insurance coverage options?*

  • Acknowledgement and Signature

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

    NOTICE: 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 each individual 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 listed 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 still provide approved documentation.

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