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Patient-Centered Care


Patients shall complete the Financial Assistance Program Application and shall provide GRMC with the documents listed on the Application. See Below.

Please Provide:

1. Proof of Identity - One of the following:

  • Copy of Social Security Card
  • Copy of state issued driver's license
  • Other photo ID
  • Proof of State of New Mexico legal residency
    Patients who do not meet the Resident Status criteria may be eligible for financial assistance under the following circumstances
    • The patient is treated for an emergency medical condition. See, paragraph 2.8 of the policy
    • The patient is treated for signs/symptoms of a communicable disease whether or not the symptoms were caused by a communicable disease; or
    • The patient was given immunizations.

2. Proof of Monetary Assets - All of the following (if applicable):

  • Last two months checking account statements
  • last two months of savings account statements
  • Documentation about stocks, bonds, and/or CDs
  • Money market accounts
  • Annuities
  • Pensions

3. Verification of Current Address- One of the following:

  • Rent receipt
  • Utility bill

4. A copy of a state Medicaid decision/denial notice.

5. Proof of Income

  • If employed, include a copy of prior year tax return, including W2 or check copies or check stubs from each of the prior three months.
  • If receiving public assistance, include copies of public assistance checks from each of the prior three months or award letter (i.e.,disability,unemployment pay stubs,or sociaJ security benefits.)
  • If self employed, include Schedule C of prior year tax return and a quarterly accountant report with a written statement declaring gross income received during the last three months.
  • If not receiving a consistent income, write a brief paragraph on a separate paper stating your financial situation over the last three months. Explain how or from what source you are receiving monies to pay for your basic living expenses such as food and housing.
  • If dependent upon another individual's financial support, include a "letter of financial support.

6. Proof of Unpaid GRMC Expenses. Applications must include documentation of unpaid GRMC expenses. Any unpaid GRMC expenses must be documented by a billing invoice and a balance due statement.

CLICK HERE to download the Application as a PDF

If a patient does not accurately complete the application process or supply the necessary documentation to determine eligibility within 30 days from the date of service, or the information supplied cannot be verified, the patient will be deemed ineligible for assistance under the Program.

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