Apply for Assistance

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 and the files you attach are converted into one password-protected document that only the board can open, and they are never stored unprotected on our web server. Read our privacy notice.

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

Applying on paper

The online form is not meant to be printed. Print the paper application at ruidosohospicefoundation.org/application-form.pdf, which has the same questions and a checklist of the documents to enclose, and mail it to Ruidoso Hospice Foundation, P. O. Box 555, Ruidoso, NM 88355.

These are the same questions as the Foundation's paper application. Please answer to the best of your ability and attach all the documents listed at the end. 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 if your application has been approved or denied. If you need help filling out the form, please call 505-235-8002.

Form revised November 2026. It asks the same questions as the paper application.

Applicant

First name *

Last name *

Date of birth *

SSN *Social Security Number. Sent encrypted and stored only in a password-protected file.

Phone *

Email *So we can reach you about this application.

Physical address *

City *

State *

ZIP code *

Mailing addressLeave blank if it is the same as your physical address.

Check one *

List prior physical residence if less than 1 year at the current address

List all members in the home

Everyone who lives in the household besides the applicant. Leave blank if none. A Social Security Number is required for each person listed.

Household member 1

First name

Last name

DOB

SSN *

Relationship to applicant

Income (received in the past 12 months)

Give the gross amount received over the past 12 months. Leave a line blank if it does not apply to you.

Employer

Gross amount received

Employer

Gross amount received

Unemployment

Welfare (aka TANF)

Food Stamps

SSA/SSI Benefits

VA

Pension

Workman's Comp

General Assistance

Other Income not listed

If you are employed this year, provide current check stubs verifying the type of income earned for all employment (under Documents, below).

Did the Applicant or Head of Household file a Federal/State Income Tax Return last year? *

Yes

No

If you were exempt from filing, provide proof (the tax waiver, under Documents).

Medical coverage / insurance

Does the Applicant have medical coverage? *

Yes

No

Name of InsuranceInclude a copy of the insurance card under Documents.

Does the Applicant have:

Medicare

Medicaid

Medicare Part D

Include copies of the cards, and of the Part D prescription card, under Documents.

Assets (give value)

Provide proof of any investments or other properties owned by the applicant or household unit. Leave blank if none.

Personal Home

Escrow Account

Stocks / Bonds

Investments

Checking Account

Savings Account

Do you receive other monies from a friend/relative to compensate your monthly expenses? *

Yes

No

If yes, from whom and how much per month

Lincoln County Indigent Fund

Have you filed an application with the Lincoln County Indigent Fund for assistance with medical bills within the past 12 months? *

Yes

No

If yes, may we contact the Lincoln County Indigent Fund Administrator to confirm your application and eligibility?

Yes

No

Requesting assistance for

Tick all that apply *

Home Health services related to end of life care not covered by insurance, Medicare, Medicaid, etc., including medications and medical equipment ($2500 max per year)

Hospice services not covered by insurance, Medicare, Medicaid, etc., including medications and medical equipment ($5000 max per year)

Lifeline Systems (includes $25 set up fee, and $30 per month monitoring service)

Documents

To determine your eligibility, the following documentation must be provided along with the completed application. Attach photos or scans as JPEG, PNG or PDF files, up to 16 MB each. They are added to your encrypted application and never stored separately.

Copy of Medicare/Medicaid or other insurance card *Front and back of every card the applicant has.

Copy of bank statements *4 months of current bank statements.

Proof of income *Pay stubs and/or copy of Social Security check, OR income tax return.

Tax waiverOnly if you are exempt from filing income tax.

Copy of the Prescription Plan Card (Medicare Part D)Only if the applicant has Medicare Part D.

Copy of a 3-month old utility bill *This provides proof of residency.

Authorization

I authorize the Ruidoso Hospice Foundation to review my information and the documents I have attached. *

Sending may take a minute if you attached large photos. You will be notified if your application has been approved or denied. Upon approval, your receipts must be mailed to Ruidoso Hospice Foundation, P. O. Box 555, Ruidoso, NM 88355.

Apply for assistance

Before you begin

Applying on paper

Household member 1

Household member N

Apply for assistance

Before you begin

Applying on paper

Household member 1

Household member __N__

Household member N