Scribd
Upload
145 views2 pages

HCHD Gold Card March - April Dates

1. The document provides information about applying for medical financial assistance through Community Outreach Services, including required documentation and dates/locations of assistance events. 2. Applicants must provide identification, proof of address, income, household composition, and other healthcare coverage. 3. The HCHD Patient Eligibility Department will process applications and mail results. Assistance is available at the listed locations and dates before 9am.

Uploaded by

Tina Palomares
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
145 views2 pages

HCHD Gold Card March - April Dates

1. The document provides information about applying for medical financial assistance through Community Outreach Services, including required documentation and dates/locations of assistance events. 2. Applicants must provide identification, proof of address, income, household composition, and other healthcare coverage. 3. The HCHD Patient Eligibility Department will process applications and mail results. Assistance is available at the listed locations and dates before 9am.

Uploaded by

Tina Palomares
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Community Outreach Services Access to Medical Financial Assistance 2012

Thursday March 15 8:30am NCI - Cleveland/Ripley Center 720 Fairmont Pasadena, TX 77504 Thursday April 26 8:30am United Way - Bay Area 1300 Bay Area Blvd., Bldg. A Houston, TX 77058

Must arrive before 9 a.m. to receive service.


To apply for medical financial assistance you must provide the following:
1. Identification for applicant and spouse -Texas Driver's License or ID -Visa -Student ID with picture -Birth certificate -Passport with picture -Resident Alien card -ID issued by Consulate 2. One Proof of Address: last 60 days -Utility bills -Mortgage coupon -Lease agreement -Credit card statement 3. Proof of Income: last 30 days -Last 4 check stubs, if weekly -Last 2 check stubs, if bi-weekly -Food stamp or TANF certification letter -If self employed, all pages of current Form 1040 -Texas Workforce Commission Unemployment Letter -Supplemental Security Income (SSI), SS Disability (SSD), or SS Retirement Award Letter -Court order decree for child support or divorce decree 4. Proof of Household Composition -Birth certificates of children / dependents -Baptismal record -Income tax form 1040 5. Proof of Immigration Status, if applicable -Naturalization Certificate -Passports -Resident Alien cards -Visa -Border crossing passes -Employment authorization cards 6. Proof of Other Healthcare coverage, if applicable -Insurance card (front & back) -Current month Medicaid slip -CHIP Card 7. Medicare Patients -Medicare identification Card -Bank statements (dated for the last 30 days) -Credit card statements (for the last 30 days)

*If you are pregnant, you will need to provide proof of pregnancy showing expected delivery date **Please see application for other examples of documents that can be submitted

__________________________________________________________________________________________________________

These are minimum requirements depending on each individual situation. HCHD Patient Eligibility Department will process the application then send the result in the mail.

Community Outreach Services (713) 566-6064

Strawberry CHC

Community Outreach Services Acceso a Ayuda Financiera Mdica 2012


Jueves 15 de Marzo 8:30am NCI - Cleveland/Ripley Center 720 Fairmont Pasadena, TX 77504 Jueves 26 de Abril 8:30am United Way - Bay Area 1300 Bay Area Blvd., Bldg. A Houston, TX 77058

Debe llegar antes de las 9 a.m. para recibir servicio.


Para solicitar asistencia financiera mdica debe proporcionar:
1. Identificacin para el solicitante y su pareja -Licencia de conducir o ID de Texas -Visa -ID estudiantil con foto -Acta de nacimiento -Pasaporte con fotografa -Matrcula consular -Tarjeta de residencia 2. Un Comprobante de Domicilio: ltimos 60 das -Recibos de servicios pblicos -Contrato de alquiler -Recibos de tarjetas de crdito - Recibo de hipoteca 3. Comprobantes de Ingresos: ltimos 30 das -ltimos 4 talones de cheque, si le pagan semanal -ltimos 2 talones de cheque, si le pagan por quincena -Certificacin de estampillas para la comida o TANF -Si es trabajador independiente, todas las hojas de la forma 1040 ms reciente -Carta de beneficios de desempleo Texas Workforce Comisin -Carta de beneficios de SS Suplemental (SSI), Discapacidad (SSD), o Retiro/ Jubilacin -Orden de manutencin dada por corte o acta de divorcio 5. Comprobante de Estatus Migratorio, si es su caso -Certificado de Naturalizacin -Visa -Tarjeta de Residencia -Pasaporte -Permiso de trabajo -Tarjeta Lser 6. Comprobante de Cobertura de Cuidado Mdico, si es su caso -Tarjeta de seguro (los dos lados) -Hoja del mes reciente de Medicaid -Tarjeta de CHIP 7. Pacientes de Medicare -Tarjeta de Medicare -Estados de cuenta del banco (ltimos 30 das) -Estados de cuenta de tarjetas de crdito (ltimos 30 das)

*Si est usted embarazada, deber mostrar un comprobante de su embarazo que demuestre la fecha esperada de dar a luz.

**Para ms ejemplos de los documentos que se 4. Comprobante de Composicin del Hogar aceptan, por favor lea la solicitud. -Actas de nacimiento de hijos/dependientes -Fe de Bautismo -Declaracin de impuestos forma 1040 ____________________________________________________________________________________________________________ Estos son los requisitos mnimos dependiendo en cada situacin individual. El Departamento de Patient Eligibility de HCHD procesar la aplicacin y le mandar el resultado por correo.

Community Outreach Services (713) 566-6064

Strawberry CHC

You might also like