Roswell Sertoma Hearing or Speech Assistance Request

Dear Prospective Applicant,

The Roswell Sertoma Club has limited funds and must be considered as a payer of last resort. Please follow the recommended procedure prior to applying for funding:

Contact your Health Care Provider and see if they will cover testing and/or hearing aids. Please advise as to the extent of your coverage.
Child Patient- The state of New Mexico requires individual and group health insurance policies to cover $2,200 per hearing aid every three years for children under 18 years of age, or under 21 years of age if still attending high school. Coverage includes fitting and dispensing services, including providing ear molds as necessary to maintain optimal fit, provided by and audiologist, a hearing aid dispenser or a physician, licensed in New Mexico.
Working Age Patient- contact your Vocational Rehab for assistance.
Veteran-Contact your local VA office for assistance first.

If you have attempted all of these avenues for help and have been denied, please fill out the Roswell Sertoma Club application for financial assistance and send it to us. Mail the application with Proof of Income to:

The Roswell Sertoma Club
P.O. Box 202
Roswell, New Mexico 88202-0202

PATIENT INFORMATION
Name:		Date of Birth: Age:
Address:		Home Phone:
City: Zip:		Alternate Phone:
		Email:
PARENT / GUARDIAN / SPOUSE INFORMATION
Mother / Guardian:		Father / Guardian:
Address:		Address:
City: Zip:		City: Zip:
FINANCIAL INFORMATION
Employer:		Employer:
Address:		Address:
Phone:		Phone:
Position:		Position:
HOME AND ASSETS
Gross Monthly Income: $		Gross Monthly Income: $
Checking Account: $		Checking Account: $
Savings Account: $		Savings Account: $
(Verification of income must accompany this application (such as IRS Tax Return, pay stubs or income verification from employer).
OTHER INCOME
Child Support: $		Pension: $
Commissions: $		Rental Income: $
Shared Living: $		Alimony: $
Disability: $		Interest: $
Stocks, Bonds, Annuities: $		Other: $
AUTO(S): YEAR / MAKE / MODEL


ALLOWABLE FINANCIAL LIABILITIES / MONTHLY EXPENSES
MONTHLY		BALANCE
House / Apartment	$	$
Car / Transportation	$	$
Medical / Dental	$	$
Loans (non credit card)	$	$
Utilities	$
Child Care	$
Insurances	$
Groceries	$
TOTAL MONTHLY EXPENSES	$	BALANCE TOTAL $
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