How to Get Your Harris Health Financial Assistance
There is no cost to make a Harris Health Financial Assistance Application
To obtain Harris Health financial assistance you must complete Harris Health’s “Application for Financial Assistance.” Be sure you, your
spouse, and ALL children between 18 and 26 years old who live with you sign and date the form.
Harris Health System’s staff is able to enroll you in patient assistance programs available with drug manufactures if you complete the Medication
Assistance Program (MAP) Consent and Authorization (Form #283233). This form allows Harris Health System to share your health information
requested by drug manufacturers and to sign other forms that are necessary to complete your application if you qualify for assistance.
Please Provide Harris Health System copies of:
1. Identification of you and if applicable, your spouse:
Provide either: (1) Marriage license/IRS 1040, if married; (2) Declaration and Registration of Informal Marriage, if marriage is common law; or
(3) Other proof of marriage and common law marriage AND provide one of the following forms of picture identification: (1) State-issued
driver license; (2) State-issued ID card; (3) Current student ID; (4) Current employee job badge; (5) U.S. Immigration documents; (6)
Passport with picture; (7) Foreign consulate ID card; (8) Agency letter; (9) Current Enhanced+ Public Library Photo ID Card; or (10) National
Electoral Institute (INE) photo ID card. If you do not have one of the above-listed forms of picture identification provide two of the
following documents: (1) Birth certificate (Married women may use their birth certificate showing their maiden name with either a marriage
license or their child’s birth certificate that shows their maiden name); (2) Marriage license or Declaration and Registration of Informal Marriage;
(3) Hospital or birth records; (4) Adoption papers or records; (5) Current Harris County voter card; (6) Current check stub; (7) Other federal
document showing your name and address in Harris County; (8) Social Security card; and/or (9) Medicaid card; Medicare card.
2. Gross income for the past 30 days for you, your spouse, and adult children between 18 and 26 and who are full time students
living with you:
All household members over 18 must sign and date the application so to allow Harris Health System to check the Texas Workforce Commission
employment records.
Provide all of the following, if applicable: (1) Proof of cash income; (2) Current check stubs; (3) Proof of income from rental property;
(4) Workmen's compensation; (5) Proof of dividends and royalties; (6) Proof of alimony received; (7) Proof of military pay and allowances;
(8) Child support documents; (9)Social Security award letter; (10)Retirement award letter; (11) Current IRS 1040 tax return(all pages) if
self-employed; (12) Veteran Affairs letter or check; (13) Agency letter; (14) Unemployment benefits record; (15) Income on SNAP form
TF0001; (16) Harris Health System-Statement of Self Employment Income Form if no tax return is filed; (17) Harris Health System-Wage
Verification Form (for cash and personal check wages only); and (18) Harris Health System-Statement of Support Form, if no income.
3. Address with your name or your spouse’s name:
Provide one of the following documents dated within the last 60 days: (1)Utility bill; (2) Check stub; (3) Mortgage coupon; (4) Credit card
statement; (5) Business mail; (6) Medicaid or Medicare letter; (7) School record for children under 18; (8) Certification documents or benefit
checks from Social Security Administration or Texas Workforce Commission; (9) Certification paper from Supplemental Nutrition Assistance
Program (SNAP), or SNAP Form TF0001; (10)
Agency letter; (11) Statement from a licensed child care provider; or (12)
Harris Health System-
Residence Verification Form filled out by a non-related person not living in your house. If you do not have one of the above documents
dated within the last 60 days, provide one of the following documents dated within the last year: (1) Lease agreement; (2) Property
tax document; (3) Department of motor vehicle record; (4) Automobile insurance document; (5) Harris County voter card; (6) Automobile
registration; or (7) Printout from IRS of most current year's tax filling.
4. Documentation of Dependent Children Living With You:
Provide one of the following documents: (1) Birth certificate; (2) Baptismal record; (3)Proof of full time school enrollment for students 18
to 26; (4) Social Security award letter with dependent’s names; (5) Baby’s Popras forms; (6) U.S. Immigration applications with dependents’
names; (7) Divorce decree or child support document; (8) Death certificate for previous household members; (9) School documents or
insurances documents showing names of both parent and child; (10) Birth fact record or hospital armband for infants less than 90 days old;
or (11) U.S. Department of
Health and Human Services- Office of Refugee
Resettlement-Verification of Release Form (ORR UAC/R-1) for
Unaccompanied alien child.
5. Immigration Status for you, your spouse, and your dependent children: Provide current or expired documents from the U.S.
Citizenship and Immigration Services.
6. Health Care Coverage for you, your spouse, and your dependent children: Provide current proof of Medicaid, CHIP, CHIP Perinatal,
Medicare, or health insurance.
7. If you have Medicare and are eligible for Harris Health Financial Assistance Program: You must fill out a Medicare Asset Form
and show proof of your current resources and liabilities (all pages of bank statements, credit card, bills, loans, etc.).
8. You must fill out papers for programs such as but not limited to CHIP, CHIP Perinatal, Medicaid, Marketplace, TANF
(Temporary Assistance for Needy Families), SSI (Supplemental Security Income), Title V or Healthy Texas Women Program
(HTWP) if you can have these programs. To download and print the TX Medicaid /CHIP application, please go to:
https://yourtexasbenefits.com.
Harris Health’s Financial Assistance Program is not an insurance plan. Harris Health System does not provide health insurance coverage under the Federal Health
Insurance Marketplace Exchange. 283117 │ 04.23 │Page 1 - Front
For Renewal Applicant (except Medicare applicant): If your name, address,
marital status, legal status, number of household member(s), and/or health care
coverage has not changed since the expiration of your prior application, please
complete and submit this application along with your family gross income for the
past 30 days only. Please visit the website below for more information:
https
://www.harrishealth.org/access-care-hh/eligibility.
Mail Application to:
Harris Health Financial Assistance Program
P.O. Box 300488, Houston, TX 77230
If you have any questions, call the Eligibility
Call Center at 713-566-6509.
APPLICATION FOR FINANCIAL ASSISTANCE
This is an Official Government Record. False or incomplete information given on this form may result in criminal action being taken under Section 37.10 or other sections of
the Texas Penal Code.
There is no cost to make a Harris Health Financial Assistance Application
Name:______________________________________________________ Maiden name:__________________________________
Home Address:_____________________________________________ Apt#: _________________ County:__________________
City:________________ State:_____________ Zip Code:__________ Email Address:____________________________________
Mailing Address: ____________________________________________City_______________State:_________Zip Code:_______
Home Telephone #:__________________ Work Telephone #: __________________Mobile Telephone #:__________________
Marital Status: Single Married Separated Divorced Widowed Common Law/Informal married
Household members:
First Name
Relationship
Date of Birth
Social Security #
Race
Ethnicity
Sex
Employed
Legal Status
SELF
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
White Black
Asian Other
Unknown/No answer
American Indian
Alaska Native
Pacific Islander
Hispanic/
Latino
Not
Hispanic/
Latino
M
F
Yes
No
US citizen
Legal Resident
Undocumented
Work permit
Sponsored
Visa
Harris Health’s Financial Assistance Program is not an insurance plan. Harris Health System does not provide health insurance coverage under the Federal Health
Insurance Marketplace Exchange. 283117 │ 04.23 │Page 2 - Front
Please complete the Household Income and Household Expenses sections
Important Information for Former Military Services Members – Women and men who served in any branch of the United States Armed
Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and
services. For more information, visit the Texas Veterans Portal at https://veterans.portal.texas.gov.
Are you a veteran? Yes No
Is anyone pregnant?
No
Yes, who? ________________________________________________________________Expected Due Date:____________________________________
Does anyone have health insurance? No Yes,
who? _________________________________________________
Name of Insurance Company:________________________________________________________________________________________________________________________ Member #: ______________________________________________________________
Do you or a member of your household receive Medicare because of disability or ALS or ESRD?
No Yes, w
ho?_______________________________________________
Have you or a member of your household applied for any Social Security benefits? No Yes,
who? _______________________
When? ________________________
Is there a medical need? No Yes
You must report any changes of name, address, marital status, legal status, income, household members, and health care coverage right away.
Failure to report these changes may mean you lose your assistance from Harris Health System and may be responsible to pay the costs of care
from Harris Health System. Harris Health System has the right to ask for more information.
I certify under penalty of law that the information I have given to Harris Health System is true and complete to the best of my knowledge. My
signature authorizes the release of information to Harris Health System vendors, contractors, state and federal agencies, or patient assistance
programs to review records for auditing purposes.
Harris Health’s Financial Assistance Program is not an insurance plan. Harris Health System does not provide health insurance coverage under the Federal Health
Insurance Marketplace Exchange. 283117 │ 04.23 │Page 2 - Back
HOUSEHOLD INCOME
(List all gross income for your family.)
Name of person working or
getting money
Source of Income/Company Name
How Often? (Weekly, Bi-weekly,
Twice A Month, Monthly)
Amount
$
$
$
$
$
Are you a current Harris Health System employee? Yes No
If yes, please list the current income received from Harris Health System.
Are you a Harris Health System retiree? Yes No
If yes, please list any income received from Harris Health System.
Are you a former Harris Health System employee? Yes No
HOUSEHOLD EXPENSES
(List the amount for each expense that you pay. For the expenses that you do not pay, write “0”.)
EXPENSES
MONTHLY AMOUNT
Rent/Mortgage/Housing
$
Utilities (gas, water, electricity, telephone, cable)
$
Food
$
Insurance (car, home, other)
$
Car Payment
$
Medical Expenses
$
Loans/Credit Cards
$
Other –Explain
$
Total Monthly Expenses
$
Who paid for the household expenses? Myself Supporter
APPLICANT’S AFFIRMATION OF RIGHTS AND RESPONSIBILITIES
By signing this application for assistance, I affirm the following:
I affirm under penalty of perjury that the information on the application and its attachments is true and correct. This application is a legal
document. Deliberately omitting information or giving false or misleading information may cause Harris Health System to terminate
services to me or a member of my household/family.
I understand that if I deliberately omit information or give false or misleading information, I may be required to reimburse Harris Health
System and the State for the services rendered if I am found to be ineligible for services.
I will report changes in my household/family situation, including changes in income, household/family members, and residency that
affect eligibility during the certification period within 14 days of the change.
I authorize the release of all information, including but not limited to income and medical information, to the Texas Health and Human
Services Commission (HHSC), the Texas Department of State Health Services (DSHS), or Harris Health System in order to determine
eligibility, to bill, or to render services to me or my household/family.
I understand that Harris Health System may ask me to provide proof of any of the information provided in this application.
I must report to Harris Health System any health insurance coverage, including but not limited to individual or group health insurance,
health maintenance organization membership, Medicaid, Medicare, Veterans Administration benefits, TRICARE, and Worker’s
Compensation benefits.
Because benefits from health insurance may be considered the primary source of payment for health care received, I hereby assign to
Harris Health System any such benefits as well as any payment for benefits and services received from and through Harris Health
System directly to the service providers.
I understand that to maintain program eligibility, I will be required to reapply for assistance at least every twelve months and potentially
sooner if I am identified as eligible for any type of third-party assistance.
I am a bona fide resident or am a dependent of a bona fide resident of Harris County for Harris Health Financial Assistance and a
resident of Texas for grant programs. I physically live in Harris County, maintain living quarters in Harris County, Texas, and do not
claim to be a resident of another county or state.
Some programs provide care through program-approved providers. I understand that to receive benefits from such programs, treatment
must be received through those program-approved providers.
I understand I have the right to file a complaint regarding the handling of my application or any action taken by the program with the
HHSC Civil Rights Office at 1-888- 388-6332.
I understand that I will receive written documentation concerning the services for which my household/family or I am eligible or
potentially eligible.
With few exceptions, I have the right to request and to be informed about information that the State of Texas collects. I am entitled to
receive and review the information upon request. I also have the right to ask the state agency to correct any information that is
determined to be incorrect. See http://www.dshs.state.tx.us; Texas Government Code §§ 552.021, 552.023 and 559.004.
If I provide Harris Health System with my e-mail address, I agree to receive e-mail communications from Harris Health System about me
and my family/household’s financial assistance plan and eligibility. If I provide Harris Health System my e-mail address, I will keep
my e-mail address current. I agree that e-mail may not be a private communication between me and Harris Health System because
anyone with access to my e-mail account, such as a family member or employer, may be able to access these e-mail communications.
I authorize the Texas Workforce Commission (TWC) to release the Unemployment Insurance claims records, Wage Record, or other
record to Harris Health System. I understand that these are the records of a state agency, and I expressly authorize that agency to release
these records to the Harris Health System for the following purpose: to process my application for Harris Health Financial Assistance
Program. This Authorization shall be valid for a period of twelve months from the date of execution set forth below, or until my written
revocation is received by TWC. This release shall apply to all time periods of records held or maintained by TWC unless specifically
limited herein.
I have read the “
APPLICANT’S AFFIRMATION OF RIGHTS AND RESPONSIBILITIES” Yes No
You, your spouse and all children 18 to 26 years old who live in your house must sign and date to get a Harris Health Program with prescriptions
Your signature:
Date:
Signature of your spouse if married or common law:
Date:
Signature of your child 18 to 26 years old who lives in your house:
Date:
Signature of your child 18 to 26 years old who lives in your house:
Date:
Witness signature (if any line is signed with an “X”):
Date:
Harris Health’s Financial Assistance Program is not an insurance plan. Harris Health System does not provide health insurance coverage under the Federal Health
Insurance Marketplace Exchange. 283117 │ 04.23 │Page 3 - Front