Indigent Services

Diane Baca
Indigent Coordinator

417 Gidding St., Suite #100
Clovis, NM 88101
Phone: (575) 763-6016
Fax: (575) 763-3656
Email

 

 


How To Apply
The patient must apply at the hospital or ambulance service. The institution will fill out all of the necessary paper work and submit it to the Curry County Indigent Office. The Indigent Fund will only accept applications from hospitals or ambulance services. Curry County Indigent Fund will pay for physician care, medication, and dental care at La Casa de Buena Salud, Clovis Clinic, if funds are available.

Summary of Qualifications
1.  You must reside in Curry County ninety (90) days prior to admittance.

2.  You must provide proof of your residency as follows:

  • You must provide proof that you have been a resident of Curry County for ninety (90) days before your admission to Plains Regional Medical Center (Clovis or other medical facility).
  • Include three (3) months prior to date of services; a three-month printout of a utility bill such as: electric, gas, telephone, water, or cable; or, a rental agreement, mortgage contact, automobile loans, personal loans, finance companies, medical expenses, credit cards, insurance premiums (health, life, or automobile), babysitter, or any receipts that would show proof residency; or, two notarized proof of residency forms may be completed by a non-relative landlord or individual only if you do not have expenses listed above.

3.  An applicant’s last income tax return must be submitted. Annually a married couple cannot make over $26,000.00 income and a single person cannot make over $17,000.00. (Note: A single person filing as head of household would be considered under the married income guidelines.)

  • All W-2’s must be included with last year’s 1040 Federal and State Income tax returns. If an income tax return was not filed, include a notarized waiver with a copy of your social security card.
  • Include all income you are currently receiving. This will include: check stubs of wages, social security, VA benefits, retirement pensions, military allotments, unemployment, welfare, educational grants, child support, and/or any other income.

4.  Curry County must receive the application within ninety (90) days after dismissal from the hospital or ambulance. If the hospital or ambulance services needs more than ninety (90) days to finish the application, they must submit an extension letter requesting additional time.

5.  If the hospital is not in Curry County, there must be a letter from a physician in Curry County referring applicant to that hospital. The referral must accompany the patient and state the reason services could not be provided in Curry County.

Forms and Documents:

Indigent Application
Proof of Residence
Income Source Verification
Tax Waiver
Hospital Claims Policy