Application

Apply for assistance

Fill in the form below, or download the paper form. If you need help with the application, call 505-235-8002.

Before you begin

Individuals are eligible if they meet the Foundation's requirements and have been residents of Lincoln County for at least ninety (90) days. Medically indigent means that the person, or the person's spouse or dependent, is unable to pay for covered services after attempting to pay and exhausting all other financial resources, and meets the income criteria for the household.

Applicants do not have to be receiving home-health or hospice services. The person to receive services must be diagnosed with an incurable illness with a life expectancy of 12 months or less.

Your privacy. This form is sent over an encrypted connection. Your application is converted into a password-protected document that only the board can open, and it is never stored unprotected on our web server.

Income eligibility by household size
Household members	1	2	3	4	5	6	7	8
Annual income	$28,950	$34,200	$39,375	$44,550	$48,750	$52,950	$57,075	$61,275
Monthly income	$2,413	$2,850	$3,283	$3,713	$4,063	$4,413	$4,757	$5,107

Please fill in the questions to your best ability. Fields marked * are required. By clicking Apply now at the bottom of this form you authorize the Ruidoso Hospice Foundation to review your information. You will be notified in writing of approval or denial.

Applicant

First name *

Last name *

Phone *

Date of birth *

Social Security Number *Required to process your application. Sent encrypted and stored only in a password-protected file.

Street address *

City *

State *

ZIP code *

How long have you lived in Lincoln County? *

Please describe your current housing *

Person needing care

I am applying for myself

First name

Last name

Relationship to you

Diagnosis *The person must have an incurable illness with a life expectancy of 12 months or less.

Hospice or home-health provider, if any

Household members

List everyone who lives in the household besides the applicant.

Household member 1

First name

Last name

Date of birth

Relationship

Annual income

List each type separately. Give totals for the past 12 months for the whole household. Put 0 if none.

Income from employment *

Names and dates of current and former employers (last 2) *

Social Security and other income

Unemployment income

Assets

Checking and savings balances

Other assets (vehicles, property, investments)

Describe any other assets or resources

Your request

What assistance do you need? *

Estimated amount

Other agencies or programs you have applied to

Authorization

I certify that the information above is true and complete, and I authorize the Ruidoso Hospice Foundation to review and verify it for the purpose of considering my application. *

Type your full name as your signature *

A board member will contact you after reviewing your application.

Apply for assistance

Before you begin

Household member 1

Household member __N__

Household member N