Sliding Fee Scale Application - Sierra Vista Hospital - svhnm 2026

1. Click ‘Get Form’ to open the Sliding Fee Scale Application in the editor.
2. Begin by entering your personal information, including your name, address, and contact numbers. Ensure all fields are filled out accurately.
3. List all household members in the designated section. Include their names, relationships to you, dates of birth, and other required details.
4. Provide information regarding your income sources. Fill in the income section with details about each person working or receiving money in your household.
5. Review the fraud penalties and responsibility to report changes sections carefully before signing. Ensure you understand these important statements.
6. Finally, sign and date the application at the bottom. If assistance was provided, include the witness signature as well.

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