Harris County Gold Card Printable Application Form 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 For Renewal Applicant except Medicare applicant If your name address
The Harris Health Financial Assistance Program is for patients living in Harris County There is no cost to make a Harris Health Financial Assistance Application If you are asked for money to fill out or approve your application do not send any money Please report these incidents to Harris Health s Compliance Hotline at 844 565 0621 GOLD CARD APPLICATION RENEWAL You can mail out the documents to Harris Health Financial Assistance Program P O Box 300488 Houston TX 77230
Harris County Gold Card Printable Application Form
Harris County Gold Card Printable Application Form
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Harris County Gold Card How To Apply For Harris Health Gold Card Houston Gold Card Youtube
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Harris County Gold Card How To Apply For Harris Health Gold Card Houston Gold Card Youtube
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1 Identification Identification is needed for both you and your spouse if you re married This would include a marriage license or Registration of Informal Marriage if you are common law One proof of identity is needed if you possess the following Driver license Current state ID Employment badge US immigration documents Who Should Apply For Gold Card Insurance Harris County residents who are uninsured homeless or recently unemployed are encouraged to apply for the Gold Card Many people believe that if you are uninsured there are no medical care options for you however this is false
1 On line HCHD 283117 2024 Form The most convenient method to deal with most forms is to complete and send them on the internet However it is important to check with the beneficiary if e filing is appropriate 2 If you have any questions please give us a call at 855 996 9939 Mon Fri 8am 6pm Or call Harris Health Marketplace Hotline at 713 592 4900 Mon Fri 8am 4pm Thank you for your attention and welcome onboard English Espa ol 2022 Open Enrollment Period is now November 1st to January 15th 2022 for Individual Family and Group health
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Form may result in criminal action being taken under Sections 31 04 37 10 or other portions of the Texas Penal Code If someone other than your spouse supports you he she must fill out this form Client s Name Supporter s Name Supporter s Relationship to Client Supporter Receives Income From 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 way to complete the Gold card Harris form on the web To start the blank utilize the Fill camp Sign Online button or tick the preview image of the blank The advanced tools of the editor will lead you through the editable PDF template Enter your official identification and contact details Send harris county gold card via email link or fax You can also download it export it or print it out 01 Edit your harris health gold card application online online Type text add images blackout confidential details add comments highlights and more 02 Sign it in a few clicks
Harris County Gold Card Form Fill Out And Sign Printable PDF Template SignNow
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How To Apply For Harris Health Gold Card 2020
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https://www.harrishealth.org/SiteCollectionDocuments/eligibility/applicant-forms/English/application-instructions-english.pdf
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 For Renewal Applicant except Medicare applicant If your name address
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The Harris Health Financial Assistance Program is for patients living in Harris County There is no cost to make a Harris Health Financial Assistance Application If you are asked for money to fill out or approve your application do not send any money Please report these incidents to Harris Health s Compliance Hotline at 844 565 0621
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Harris County Gold Card Printable Application Form - Who Should Apply For Gold Card Insurance Harris County residents who are uninsured homeless or recently unemployed are encouraged to apply for the Gold Card Many people believe that if you are uninsured there are no medical care options for you however this is false
