HCAP Application:


To apply for the Health Care Assistance Program, please complete the following form, then call (505) 867-2292 ext 1734 to make an appointment.

Client Details:


First Name:
Middle Name:
Last Name:
Date of Birth:
SSN:
Gender:
Address:
City:
State:
Zip:
Phone 1:
Phone 2:
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip:


Application Questions:


U.S. Citizen?



Marital Status?



Please mark one or more to indicate what this person considers himself/herself to be (optional).


Other:


To verify residency you are required to submit (one) of the following documents. Please select which document you will submit and bring it to your appointment.

Current Driver's License  
Apartment Rental Lease Contract  
Property Tax Bills  
Voter's Registration  
A Current Utility Bill such as Electric, Gas or Water  
Verification of Residency Letter  


To verify income, you are required to submit (one) of the following documents. Please select which document you will submit and bring it to your appointment.

Check stubs for the past 60 days  
Most current Income Tax Return  
Disability, pensions, retirement, Social Security, veteran benefits, student loans, scholarships, Unemployment, grants or other financial support you are receiving  
If self employed – most recent Income Tax Return, including state/federal forms with W-2's, Schedules C, C-EZ Schedule K or F, a signed itemized profit and loss statement for the last three months and NM Gross Receipts  
If unemployed – provide a notarized letter stating how applicant's expenses are being sustained  


Your eligibility is dependent on your income. Please review the income limits below and check the household income box that applies to you. If your income exceeds that listed for the number in your household, please click cancel below as you are not eligible for assistance at this time.


HOUSEHOLD NUMBERAMOUNT
1$2,322.00
2$3,152.00
3$3,981.00
4$4,810.00
5$5,640.00
6$6,469.00
7$7,299.00
8$8,128.00