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Application for Financial Assistance - Texas
What Is a Harris County Gold Card Application?
The Harris County Application for Financial Assistance is a legal application completed by low-income Harris County residents to apply for healthcare financial assistance. The Harris Health System has established the criteria to determine if an applicant has a need for affordable, sliding-scale healthcare. When using this application, eligibility depends on your place of residence, gross monthly income, Medicare enrollment, and the number of household members. This kind of assistance provides fewer benefits than traditional health insurance plans, however, the Gold Card program is still a lifeline that makes clinic visits and medications more accessible.
Alternate Name:
- Harris Country Gold Card Application.
This form was released by the Harris Health System and the latest version of the form was issued on May 1, 2019 , with all previous editions obsolete. You can download a Harris County printable Gold Card Application through the link below. In addition to the application, you will need proof of identification, current address, a resume of your gross income, proof of your relationship to the children who depend on you for support, immigration status, and health care coverage.
How to Fill Out a Harris County Gold Card Application?
Provide the following information in the Gold Card Application Form:
- Write down your name, maiden name, home address, email address, telephone numbers. Indicate your marital status - single, married, separated, divorced, widowed, common law / informal married;
- State personal details of your household members - their full names, relationship to you, dates of birth, social security number, races, ethnicities, sexes, employment status, and legal status;
- If anyone in your household is pregnant, has applied for Social Security benefits, or has health insurance, name these individuals. State the name of the insurance company and the insurance number;
- Describe your household income. Name the individuals who work or get money, indicate the source of income, and how often the money is received. If you are a current, former Harris Health System employee or retiree, check the appropriate boxes;
- List the monthly amounts of your household expenses - housing, utilities, food, insurance, car payments, medical expenses, loans, credit cards, etc. Name the individual who paid for these expenses;
- Carefully read your rights and responsibilities on the last page of the form. Certify the statements in the form are true and correct to the best of your knowledge and authorize the release of information to Harris Health System by signing the application. The form also requires signatures of your spouse and children 18 to 26 years old who live in your house. If any line is signed with an "X", a witness must be present at the signing.
Once you fill out the application, mail it to the Harris Health Financial Assistance Program, PO Box 300488, Houston, TX 77230, or submit the documents at one of the five Eligibility Centers in Houston. You will receive confirmation of receipt from the office within ten days and acceptance or rejection within fourteen days. If you want to check your Harris County Gold Card Application status, contact the nearest Eligibility Center.
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