An application can be picked up at the contracted Medical Provider’s business office or at the Chaves County Healthcare Office at #1 St. Mary’s Place Suite 160, Roswell, NM 88203. You may also call (575) 624-6535 or (575) 624-6545 and an application will be mailed to you. You are also able to print the application from the “Forms” section to the left of this page.
Your application should be returned to the local Medical Provider you received services from. If the provider is located out of Chaves County, your application should be returned to the Chaves County Healthcare Office. Office hours are Monday – Friday 8:00am – 5:00 pm unless there is a holiday.
- A signed copy of all household members Income Tax returns. (If an adult member is not required by law to file a State or Federal Income Tax then that member must fill out a Tax Waiver.)
- Self Employment Individuals: Self employed individuals must provide a complete federal return, CRS 1 Reports for one quarter. Income Tax Forms must be signed by whomever filed.
- Proof of residency for all members who reside within the household: A Tax Return, Utility bill, rent receipt, Driver’s License, Identification card, anything that has a date stamped on it, or a Proof of Residency form can be filled out if none of the above is available.
- Verification of Income: One month worth of consecutive pay stubs, if applicable awards letters from the following: Social Security, V.A., Pensions, Retirement, Child Support, General Assistance (TANF), Food Stamps, a letter of support from the individual who is supporting you but not living within the household. (Monetary amount of support must be included on the letter.) If property investments, stocks or bonds are owned, please provide proof of what it/they are worth.
- Copies of Social Security Cards
- Photo ID’s are required on all applications
- Copies of all medical insurance cards (if applicable)