Hchd Gold Card Application Form – Fill Out and Use This PDF

Applying for Financial Assistance:

Call

‐

to schedule an appointment or

There is No Fee for a Gold Card. If you are asked to pay for a Gold Card, please re

ort this to 713­566­6277.

or

Drop off to the nearest Eligibility Center

Mail to

(C(D Financial Assistance Program

P.O. Box

(ouston, TX

Please provide copies of the following papers:

State issued driver’s license, state issued )D card, current student )D with picture, current employee job badge with picture ,

passport with picture, U.S. )mmigration documents with picture, credit card with picture, foreign consulate )D card with

Identification (ID) (One for you and your spouse)

not for married women ,

picture. )f picture )D is not available, two of the following proofs may be used: birth certificate

marriage license, social security card, other federal documents showing identity, hospital or birth records, adoption papers or

records, voter’s registration card, current wage stubs, Medicare card or current Medicaid.

days:

One proof of address that shows your name or your spouse’s name dated within the last

Utility bills, school record for children under age

, mortgage coupon, credit card statement, printout from )RS of most

Address

current year’s tax filing, certification documents or benefit checks from Social Security Administration or Texas Workforce

Commission, certification documents from SNAP

Supplemental Nutrition Assistance Program, formerly known as food

stamp , Medicaid or Medicare, letter from recognized social services agency, business mail, statement from a licensed child

care provider, (arris County (ospital District Residence Verification Form completed by a reliable person not living in the

same household or (arris County (ospital District Rental Verification Form completed by landlord.

OR

One proof of address that shows your name or your spouse’s name dated within the past year:

Current lease agreements, department of motor vehicles record, property tax documents, automobile insurance documents

non expired , automobile registration or voter’s registration card for current year.

Current check stubs, child supports, current )RS

tax return, (arris County (ospital District Statement of Self

Employment )ncome Form, (arris County (ospital District Wage Verification Form, Social Security, Retirement or Veteran

Income for

past 30 days of each household member

Affairs letter or check, unemployment benefit records or (arris County (ospital District Statement of Support Form if no

income.

to

, Social Security Award letter

Birth certificate, baptismal record, proof of full time school enrollment for students aged

with dependent’s names, school documents or insurance documents showing names of parent and child, U.S. )mmigration

Household members (one for each)

applications with dependents’ names, divorce or child support decree, baby’s Popras form, birth fact record or hospital

armband for infants under days old, current Medicaid or Death Certificate for previous household members.

You must bring documents from the U.S. Citizenship and )mmigration Services.

Immigration Status (for each household m mber)

Please bring current proof of Medicaid, C()P, C()P Perinatal, Medicare or health insurance.

H lth Care Cov rage (for each household memb

)

You must provide proof of your resources and liabilities current bank statement, credit card bills, loans, etc. on a Medicare

Asset Form.

Medicare patients

Resources f

or SS) Supplemental Security

*You must apply for C()P, C()P Perinatal, Medicaid, TANF Temporary Assistance for Needy Families

)ncome benefits if you qualify.

)f you need help getting proof, the interviewer can help you.

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Name:

______________________

______________

______________

Maiden Name:

______________________________

Home Address: ________________________________________________

Apt #: ______

County: _______________________

City: __________________________________________________________

State: ______

Zip Code: _____________________

Home Telephone #: __________________

Work Telephone #: __________________

Patient Identifier #: ___________________

Martial Status:

† Single

† Married

† Separated

† Divorced

† Widowed

† Common Law

(ave you ever been to Ben Taub, LBJ or Quentin Mease (ospitals?

†

Yes

†

No )f yes, when? ____________________________

Last Name

First Name

Relationship Date of Birth

Social Security #

Race

†Sex

Employed

Legal Status

Household Members:

SELF

†

M

†

Yes

†US Citizen

†Work Permit

†Legal Resident

†Sponsored

†F

†No

†

†

†Undocumented

†Visa

†

†US Citizen

†Work Permit

†

M

†

Yes

†Legal Resident

†Sponsored

†F

†No

†Undocumented

†Visa

†

M

†

Yes

†US Citizen

†Work Permit

†Legal Resident

†Sponsored

†F

†No

†Undocumented

†Visa

†

M

†

Yes

†US Citizen

†Work Permit

†Legal Resident

†Sponsored

†F

†No

†Undocumented

†Visa

†

M

†

Yes

†US Citizen

†Work Permit

†Legal Resident

†Sponsored

†F

†No

†Undocumented

†Visa

†

M

†

Yes

†US Citizen

†Work Permit

†Legal Resident

†Sponsored

Household In ome: include all income in the family

F

No

Undocumented

Visa

Wages, Rental Property, Child Support, Alimony, Unemployment Benefits, SS), RSD), SSD, Cash Contributions, Workmen's Compensation, Self‐

Employment current

income tax , TANF, VA Benefits, Pension, Retirement, Adoption Subsidy, Government Assistance.

Name of person working or getting money

Source of )ncome/Company Name

(ow Often? weekly, bi‐weekly, twice

Amount

a month, monthly

)s anyone pregnant?

Yes

No

†

Yes

)f

yes, who? ______________________________

Expected Delivery Date:

_____________

Does anyone have health insurance?

No

)f yes, who? ___________________

Name of )nsurance Company: _________

†

†

†

†

Member #: ________________________

†

Yes

No

)f yes, who? _____________________

When? _________

(ave you or a member of your household applied for SS)?

Unemployed?

†

Yes

†

No

Last day worked:

Name of Company: ______________________

You must report any changes of name, address, marital status, legal status, income, household members, and health care coverage immediately.

Failure to report these changes may result in losing your assistance from (C(D and/or being responsible for repayment of the costs incurred by

(C(D in providing your medical care.

) certify under penalty of law that the information ) have provided to (C(D is true and complete to the best of my knowledge. My signature

authorizes the release of information to (C(D vendors, contractors, state and federal agencies, or patient assistance programs to review records

for auditing purposes.

Signature:

Date:

Witness Signature (if applicable):

Date:

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