Navigating healthcare costs can be challenging, especially for individuals and families facing financial hardship. In Texas, Harris Health System offers a vital Indigent Care Program designed to provide financial assistance for necessary medical services. To access this program and ensure a smooth application process, understanding the required documentation is crucial. This guide outlines the essential papers you need to gather when applying for the Harris Health System Financial Assistance Program, which includes indigent care. Proper preparation with these documents will help you demonstrate your eligibility and move forward in receiving the healthcare support you need.
Essential Documents for Your Application
Harris Health requires specific documentation to verify your identity, residency, income, family relationships, immigration status, and existing healthcare coverage. Gathering these documents beforehand will streamline your application and help expedite the process. Here’s a detailed breakdown of what you’ll need:
1. Identification for You and Your Spouse (If Applicable)
Providing valid identification is the first step in confirming your identity and marital status, if applicable. You will need to provide documentation for yourself and your spouse if you are married.
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Proof of Marriage (If Married):
- Marriage License
- IRS 1040 tax return (if filing jointly as married)
- Declaration and Registration of Informal Marriage (for common law marriage)
- Other official proof of marriage
If declaring common law marriage and you possess the DSHS Form VS-180.1, this will serve as proof. If you do not have this form, you will need to download and complete the THHSC Form H1057 Declaration of Informal Marriage. Both partners must sign and date this form.
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Photo Identification (One of the Following):
- State-issued Driver’s License
- State-issued ID Card
- Current Student ID
- Current Employee Job Badge
- Passport with Photo
- U.S. Immigration Documents
- Foreign Consulate ID Card
- Agency Letter
- Current Enhanced Public Library Photo ID Card
- National Electoral Institute (INE) Photo ID Card
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If You Lack Photo ID (Provide Two of the Following):
- Birth Certificate (Married women can use their maiden name birth certificate along with a marriage license or child’s birth certificate showing their maiden name)
- Marriage License or Declaration and Registration of Informal Marriage
- Social Security Card
- Other Federal Document showing your name and Harris County address
- Hospital or Birth Records
- Adoption Papers or Records
- Current Harris County Voter Card
- Current Check Stub
- Medicare Card or Medicaid Card
2. Proof of Address with Your Name or Spouse’s Name
Verifying your Harris County residency is essential for program eligibility. You must provide proof of address dated within a specific timeframe.
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Dated within the Last 60 Days (Choose One):
- Utility Bill
- Check Stub
- School Record for Children under 18
- Mortgage Coupon
- Credit Card Statement
- Certification Documents or Benefit Checks from Social Security Administration or Texas Workforce Commission
- SNAP Certification Documents or SNAP Form TF0001
- Letter from an Agency or Harris Health System Agency Letter
- Medicaid or Medicare Letter
- Letter from a Recognized Social Services Agency
- Business Mail
- Statement from a Licensed Child Care Provider
- Harris Health System Residence Verification Form (English, Spanish, Vietnamese) completed by a non-related person not living with you.
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Dated within the Last Year (Choose One if you don’t have a document from the list above):
- Lease Agreement
- Department of Motor Vehicles Record
- Property Tax Document
- Automobile Insurance Documents
- Automobile Registration
- Harris County Voter Card
- Printout from IRS of most current year’s tax filing
3. Gross Income Verification for the Past 30 Days
To determine financial need, Harris Health requires documentation of gross income for all household members, including you, your spouse, and children over 18 living with you. Important Note: Every household member over 18 must sign the application to allow Harris Health to verify income information with the Texas Workforce Commission (TWC).
- Acceptable Income Proofs:
- Cash Income, Dividends, and Royalties Documentation
- Rental Property Income Records
- Alimony Documentation
- Worker’s Compensation Records
- Military Pay and Allowances Statements
- Current Check Stubs
- Child Support Documents
- Current IRS 1040/1040A Tax Return (all pages if self-employed)
- Harris Health System Statement of Self Employment Income Form (English, Spanish, Vietnamese) (if no tax return filed)
- Harris Health System Wage Verification Form (English, Spanish, Vietnamese) (for cash and personal check wages only)
- Social Security Award Letter
- Retirement Award Letter
- Veteran Affairs Letter or Check
- Agency Letter
- Income Information on SNAP Form TF0001
- Unemployment Benefit Records
- Harris Health System Statement of Support Form (English, Spanish, Vietnamese) (if no income)
4. Proof of Relationship to Dependent Children
If you are applying for assistance for children living with you, you must prove your relationship to them.
- Acceptable Relationship Proofs:
- Birth Certificate
- Baptismal Record
- Proof of Full-Time School Enrollment (for students ages 18-26)
- Social Security Award Letter with Dependents’ Names
- School Documents or Insurance Documents showing parent and child names
- U.S. Immigration Applications with Dependents’ Names
- Divorce Decree or Child Support Documents
- Baby’s Popras Form
- Birth Fact Record or Hospital Armband (for infants under 90 days old)
- Death Certificate for Previous Household Members (relevant in certain dependency cases)
- U.S. Department of Health and Human Services – Office of Refugee Resettlement-Verification of Release Form (ORR UAC/R-1) (for Unaccompanied Alien Children)
5. Immigration Status Documentation
Verification of immigration status is required for you, your spouse, and all dependent children.
- Required Documents:
- Current or expired documents from U.S. Citizenship and Immigration Services (USCIS)
6. Health Care Coverage Information
Provide proof of any existing health care coverage for yourself, your spouse, and dependents.
- Acceptable Coverage Proofs:
- Medicaid Card or Documentation
- CHIP (Children’s Health Insurance Program) Card or Documentation
- CHIP Perinatal Documentation
- Medicare Card or Documentation
- Private Health Insurance Card or Documentation
7. Medicare Asset Form (If Applicable)
If you are a Medicare recipient and are potentially eligible for the Harris Health System Financial Assistance Program, you must also complete a Medicare Asset Form.
- Required for Medicare Recipients:
- Medicare Asset Form (English, Spanish, Vietnamese)
- Proof of Current Resources and Liabilities (all pages of bank statements, credit card bills, loans, etc.)
8. Applications for Other Programs
As part of the Harris Health application, you may be required to apply for other relevant assistance programs if you are potentially eligible.
- Potential Program Applications:
- CHIP
- CHIP Perinatal
- Medicaid
- Health Insurance Marketplace
- TANF (Temporary Assistance for Needy Families)
- SSI (Supplemental Security Income)
- Title V Programs
- Healthy Texas Women Program (HTWP)
Conclusion
Applying for the Indigent Care Program in Texas through Harris Health can provide crucial financial relief for healthcare services. By diligently gathering all the necessary documents outlined in this guide, you can ensure a smoother and more efficient application process. Remember to make copies of all documents and bring them with you when you apply. For the most up-to-date information and any specific questions related to your situation, it is always best to visit the official Harris Health System website or contact them directly. This preparation will empower you to access the healthcare assistance you need and deserve within Texas.
