revised-application-august-2011Patient Enrollment Form English

spanish-enrollment-form-october-2011

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/ $1,862
2/ $2,522
3/ $3,182
4/ $3,842
5/ $4,502
6/ $5,162