Proof of Income
You must provide one of the following for EACH person contributing to your annual household income:
- Pay Stubs for the Last Two Months of Work
- Proof of Unemployment, as applicable
- Profit and Loss Statements (if self-employed)
Each file must be either jpg, jpeg, png, gif, pdf, doc, or docx with a maximum file size of 890KB. If your documents are too large or you are having issues uploading them you can email them as attachments to firstname.lastname@example.org. Please be sure to include your name and what each attached document is for.
Electronic Signature Agreement
I certify, to the best of my knowledge, that all information in this application is true and accurate. Furthermore, I agree to inform Tri-County Health Network if my family income, county of residence, or my place of work changes at any point of the year. I understand that there is no guarantee I will receive a financial scholarship. Finally, I understand that, if I receive a financial scholarship, in order for my care to be paid, I authorize my therapist to release the dates/times of my treatment and reason for visit - for payment purposes only. Any personal information that could identify me will be changed before this information is shared with the San Miguel Behavioral Health Solutions Panel Solutions.
The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.