• SpectraPlan Application

    2024
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    • Applicant Information 
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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.

    • Accepted Documentation:

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

    • Accepted Documentation:

      • Immigration forms I20 or J1
      • Refugee Cash Assistance

    • Accepted Documentation:

      • Current Income Statement
      • Prior year income tax return

    • Accepted Documentation:

      • Award Letter(s) listing amount received (current year)

    • Accepted Documentation:

      • Award Letter(s) listing amount received (current year)

    • Accepted Documentation:

      • Benefit Award Letter (current year)

    • Accepted Documentation:

      • Benefit Award Letter (current year)

    • Accepted Documentation:

      • Plan administrator documentation stating monthly
        benefit amount (current year)

    • Accepted Documentation:

      • Letter from previous employer documenting last day
        of employment
      • Letter from Case worker (agency letterhead required)
      • Tax Form 4506t
    • 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.

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    • Disclaimers and Signature 

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      If you have questions, contact Spectra Health Social Services at 701-757-2100 ext 1218.

      PLEASE READ CAREFULLY AND INITIAL BEFORE SIGNING

    • *   

      I understand that there is a nominal fee of $30 (Dental), $20 (Medical), or $3 (Specialty Behavioral Health) that is due at the time of EACH visit. Additionally, I understand that any labs processed at Spectra Health will qualify for the SpectraPlan Discount; however, any lab work that is sent to an outside lab will be my personal financial responsibility.

    • *
      Proof of income is required. Within 30days, 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 each employer of all individuals working within the household and/or authorized agencies to confirm provided income. I will be asked 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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