It is the policy of San Juan Health to provide essential services regardless of a patient’s ability to pay. We do offer financial assistance for those that qualify and discounts are based on household size and annual income. The maximum gross income per year (200% of the Federal Poverty Guideline) for one person would be $30,120 and for a household of eight, it would be $105,440 (examples given as a range for your understanding).

In order to see if you qualify for financial assistance, you must complete this form with all necessary information. For convenience, the form is available to fill out below. Please note that the form will not save your progress, so it must be done in one setting (and if you close the page or refresh the page, it will not save your progress). We strongly encourage you to review the form before starting–including checking the boxes under Household Income Types that apply to your situation–so that you understand what documentation will be required. This will allow you to gather what you need and when you are ready, you can complete the form.

If you prefer to fill out the form by hand, you can download a copy of the form here (PDF). You will need to still gather all required documentation and return the completed form to Heather Stocks by email, fax, mail, or in-person.

• Email: [email protected]
• Fax: 435.587.2061
• Mail: Attn. Heather Stocks: P.O. Box 308, Monticello, Utah 84535
• In-Person: Heather’s desk is in the lobby of San Juan Hospital

Thank you for your time and for choosing San Juan Health as your partner for your healthcare needs.