patient-enrollment-form-english-2010

translated-sfpa-application-2010Enrollment Form

 

PATIENT ELIGIBILITY

Project Access Patients must meet the following guidelines:

• Be a Santa Fe County resident
• Be referred by a health care provider
• Does not have any other type of health coverage or insurance
• Income must be within the following guidelines:

Family Size/Maximum Monthly Income
1/ $1,805
2/ $2,428
3/ $3,052
4/ $3,675
5/ $4,298
6/ $4,922