Mountain States Health Alliance d b a Johnson City 2026

1. Click ‘Get Form’ to open the Mountain States Health Alliance application in the editor.
2. Begin by entering the Application Date, Patient’s Name, Social Security Number, Date of Birth, and Account Number(s) in the designated fields.
3. In the Required Documentation section, check off each item you are providing. Ensure you have copies of your last two years of Federal Tax Returns and any other relevant documents listed.
4. Fill out the Patient/Responsible Party Information section with accurate details about yourself and any responsible party. Include their relationship to you.
5. Complete the Dependents and Monthly Expenses sections by listing all dependents and detailing your monthly expenses accurately.
6. Review your entries for accuracy before signing at the bottom of the form. Ensure that all required documentation is attached.

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