Homepage Fill Out Your Hchd Gold Card Application Form
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The Hchd Gold Card Application form offers a crucial chance for individuals and families to receive financial assistance for health care needs without incurring any fees. Completing this application is an essential step in securing access to medical services provided by the Harris County Hospital District. The form requires various types of identification, including state-issued driver’s licenses and employee job badges, alongside proof of residency and income details. Applicants must provide documentation that proves their financial status and household composition, including recent tax returns, pay stubs, and letters from recognized social service agencies. Moreover, the form emphasizes the importance of accurate information, with clear instructions regarding the consequences of submitting false claims. It also specifies necessary documentation for each household member applying, hence ensuring a comprehensive assessment of eligibility for the program. The application process can be initiated by scheduling an appointment or by reporting any fees erroneously requested for the Gold Card—since it is explicitly stated that no fees should be assessed. Thus, understanding the requirements and completing the form accurately can significantly ease the financial burden of medical care.

Hchd Gold Card Application Example

FINANCIAL ASSISTANCE APPLICATION INSTRUCTIONS

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.

 

 

 

/

Page

 

 

 

 

 

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 Sections 31.04, 37.04, 37.10, or other portions of the Texas Penal Code.

There is No Fee for a Gold Card. If you are asked to pay for a Gold Card, please report this to 713­566­6277.

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:

 

 

 

 

/

Page

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form Characteristics

Fact Title Details
Application Fee There is no fee to apply for the Gold Card. If you are asked for payment, report it to the provided number.
Required Documentation Applicants must submit identity verification documents, including state-issued IDs and proof of residency, dated within the past year.
Household Income Reporting All household income sources, such as wages and benefits, must be reported to determine financial assistance eligibility.
Residence Verification Evidence of residency can be validated by utility bills or lease agreements that include the applicant's name.
Legal Compliance Providing false or incomplete information may lead to criminal charges under Texas Penal Code sections 31.04, 37.04, and 37.10.

Guidelines on Utilizing Hchd Gold Card Application

Completing the HCHD Gold Card Application is an important step in applying for financial assistance. Once you fill out the application form, you will need to submit it along with the required documentation at an Eligibility Center or via mail. Be prepared to provide several types of identification and income verification that correlate with your household situation.

  1. Gather Required Documentation: Collect necessary documents such as state-issued ids or picture identification, proof of address, and income statements.
  2. Personal Information: Fill in your full name, including your maiden name if applicable, and provide your home address, apartment number, county, city, state, and zip code.
  3. Contact Numbers: Provide your home and work telephone numbers, and indicate your patient identifier number if you have one.
  4. Marital Status: Indicate your marital status by checking the appropriate box (single, married, separated, divorced, widowed, or common law).
  5. Previous Hospital Visits: Indicate if you’ve been to Ben Taub, LBJ, or Quentin Mease hospitals, and if so, provide the last date you visited.
  6. Household Members: List all members of your household, including their names, relationships, dates of birth, social security numbers, race, sex, and employment status.
  7. Legal Status: For each household member, check the legal status (e.g., U.S. Citizen, Work Permit, Undocumented, etc.).
  8. Household Income: Provide details about all sources of income for each household member. Include wages, child support, unemployment benefits, and any government assistance received.
  9. Health Insurance Information: If anyone in the household has health insurance, include their name, insurance company details, and member number.
  10. Pregnancy Status: Indicate if anyone in the household is pregnant and, if so, provide the expected delivery date.
  11. Employment History: If applicable, indicate if you or a household member has applied for Social Security or is unemployed, and list the last company worked for and the last day worked.
  12. Certification: Read the certification statement carefully, then sign and date the application. If applicable, include a witness signature.

Once you have completed the application, you can submit it by dropping it off at your nearest Eligibility Center or mailing it to the specified address. Make sure to keep copies of the application and all documents submitted for your records.

What You Should Know About This Form

What is the HCHD Gold Card, and who is eligible to apply?

The HCHD Gold Card is a financial assistance program that provides access to healthcare services for eligible individuals and families in Harris County. Applicants must meet specific income and residency requirements. Generally, eligible participants include low-income residents who do not have adequate health insurance coverage. It is important to gather the necessary documentation before applying to ensure eligibility.

Is there a fee associated with the Gold Card application?

No, there is no fee associated with applying for the Gold Card. If an applicant is asked to pay a fee, it is advised to report this to the designated contact number at 713-566-6277.

What documents are required for the Gold Card application?

Applicants must provide several documents, including a copy of a state-issued driver's license or ID, proof of residency, and various forms of identification for household members. Acceptable proof of residency includes utility bills or current lease agreements. Specific requirements may vary depending on personal circumstances and income sources.

How can an applicant submit their Gold Card application?

An applicant can submit their application in several ways. They can schedule an appointment by calling the designated number, drop off the application at the nearest Eligibility Center, or mail it to the specified address outlined in the instructions. It is critical to choose the method that best suits your circumstances.

What should I do if I encounter issues while filling out the application?

If you encounter any issues while filling out the Gold Card application, you can reach out for assistance. The interviewer at the Eligibility Center can provide help with gathering the necessary proofs and completing the application forms correctly.

How will I know if my application has been approved?

What should I do if my personal information changes after applying?

Applicants are required to report any changes in personal information, such as name, address, marital status, legal status, income, and household members, immediately. Failure to report changes may lead to losing assistance or being responsible for repaying costs incurred by HCHD for medical care.

Common mistakes

Filling out the Hchd Gold Card Application form can be a straightforward process, but several common mistakes can lead to delays or complications. One frequent error is not providing accurate personal information. Incomplete names, addresses, or incorrect contact details can cause confusion and hinder the processing of the application. Ensure every field is filled in accurately to avoid unnecessary setbacks.

Another common mistake involves the inclusion of required documentation. Applicants often overlook the necessity of providing supporting documents, such as a state-issued driver's license or proof of residency. Missing vital paperwork may result in immediate rejection of the application, so it’s crucial to read the requirements carefully and gather all necessary documents before submission.

Not thoroughly understanding eligibility requirements is yet another pitfall. Some applicants fail to review the guidelines regarding legal status or household income, leading to misunderstandings about what qualifies as acceptable proof. Verify your circumstances against the provided criteria to ensure you meet all necessary qualifications.

Errors in the income declaration can also jeopardize an application. Individuals sometimes neglect to report all sources of income or provide estimates instead of exact figures. It is essential to be as precise as possible to present an accurate financial profile. Failure to correctly report income may not only result in delays but could also lead to legal consequences.

Applications often suffer from a lack of clarity in explanations or descriptions. Whether it's detailing past interactions with healthcare providers or explaining your current financial situation, clarity is vital. Use clear, straightforward language to articulate your circumstances and needs, as vague or convoluted statements may lead to misunderstandings.

Another misstep often encountered is the neglect of signature or date on the application. The form is considered incomplete without the necessary signatures, which can invalidate the entire submission. Double-check that all required places are signed and dated appropriately before turning in the application.

Finally, failing to follow up after submitting the application can cause applicants to miss critical information regarding their status. Applicants should keep track of their submission and reach out if they do not receive confirmation within the expected timeframe. Proactive communication ensures any issues can be promptly addressed and resolved.

Documents used along the form

When applying for the HCHD Gold Card, several additional documents may be necessary to support your application. Providing these forms will help streamline the process and ensure all required information is available.

  • Proof of Identity: This document verifies your identity and may include a state-issued driver’s license, passport, or identification card. It is essential for establishing who you are and confirming that you meet the eligibility criteria.
  • Proof of Residence: Recent utility bills, lease agreements, or property tax documents should be provided to show your current address. This helps confirm your residency within the service area.
  • Income Verification: To assess your financial eligibility, submit recent check stubs, tax returns, or benefit statements. This documentation demonstrates your household income and financial situation.
  • Citizenship or Immigration Status Documentation: Include relevant U.S. Citizenship and Immigration Services documents. These forms establish your legal status and ensure compliance with eligibility requirements.

Gathering these documents promptly can expedite your application process. Ensure all information is accurate to avoid delays in your financial assistance request.

Similar forms

  • Financial Aid Application: Similar to the Gold Card Application, this document requires detailed personal and financial information to assess eligibility for assistance programs. Both documents request documentation proving identity and financial status.

  • Medicaid Application: Both applications seek to determine eligibility for medical assistance, requiring proof of income, household members, and relevant financial documentation.

  • SNAP Application: Like the Gold Card Application, this form focuses on household income and assets to determine eligibility for supplemental nutrition assistance. It requests many of the same supporting documents.

  • Section 8 Housing Application: This application shares similarities in its need for personal, income, and asset details to qualify for housing assistance programs.

  • Utility Assistance Application: Both documents require proof of identity and a clear representation of household income and expenses for evaluating eligibility for utility payment assistance.

  • Unemployment Benefits Application: Similar in nature, both forms require reporting of income and household information to assess eligibility for economic assistance.

  • Veterans Benefits Application: This form also seeks comprehensive financial data and identity verification, paralleling the Gold Card Application's requirements for assistance eligibility.

  • Child Support Application: Both applications focus on household income and personal details to ensure fair representation when determining support obligations or qualifications for assistance.

  • Health Insurance Marketplace Application: Similar to the Gold Card Application, this document gathers information about household size and income to assess eligibility for health coverage options.

Dos and Don'ts

Here are some important tips to consider when filling out the HCHD Gold Card Application form:

  • Do read all instructions carefully before you start the application. Familiarizing yourself with the requirements ensures you have everything needed.
  • Do provide accurate and complete information. Double-check all your entries to avoid missing critical details that could delay processing.
  • Do gather all necessary documents in advance. Having your identification, proof of address, and income information ready will make the process smoother.
  • Do keep a copy of your completed application and any documents you submit. This is important for your records and future reference.
  • Don’t pay for your Gold Card. It is free, and if someone asks for a fee, report this immediately.
  • Don’t leave any fields blank unless instructed. Incomplete information can lead to delays or denial of assistance.
  • Don’t submit any documents that are not required. Stick to the list of required papers to avoid confusion and extra processing time.
  • Don’t wait until the last minute to apply. Allow yourself enough time to gather documents and rectify any issues that may arise during the process.

Misconceptions

Misconception 1: There is a fee for the Gold Card.

Many individuals believe that applying for the Gold Card involves a fee. In fact, there is no fee associated with obtaining this card. If anyone requests payment for the Gold Card, you should report this immediately to the specified number.

Misconception 2: All documents listed must be submitted together.

Some people think they need to provide all required documentation in one submission. However, you can schedule an appointment and bring the necessary documents at that time. You are not obligated to submit everything at once.

Misconception 3: The Gold Card is only for particular demographics.

The Gold Card is available to various populations, regardless of specific demographics. It is designed to assist anyone who qualifies based on financial needs, not limited by gender, marital status, or other factors.

Misconception 4: Incorrect submissions lead to permanent disqualification.

Some applicants fear that any mistake will result in permanent disqualification. While providing accurate information is essential, errors can often be corrected. Contact the assistance program for any clarification needed.

Misconception 5: You cannot receive help if you are undocumented.

Many believe that undocumented individuals are ineligible for assistance. However, the program is designed to help low-income residents, and eligibility may still exist for undocumented immigrants based on certain criteria.

Misconception 6: The application process is overly complicated.

Concerns about the complexity of the application process deter many from applying. While the process requires specific documentation, assistance is available. Interviewers can guide you through, simplifying the steps involved.

Key takeaways

Applying for the HCHD Gold Card can be a straightforward process if you keep a few important points in mind. Here are key takeaways to assist you in completing and using the application form:

  • No Fee: There is no charge for obtaining the Gold Card. If you are asked to pay, report this immediately to 713-566-6277.
  • Required Documents: Be prepared to provide various identity and proof of income documents, such as a driver's license, social security card, or utility bills.
  • Proof of Address: You need one recent proof of address that matches either you or your spouse's name. Acceptable options include utility bills or bank statements dated within the past year.
  • Household Members: List all household members accurately, including their legal status, income sources, and medical coverage details.
  • Income Information: Ensure to include all sources of household income. This helps determine your eligibility for financial assistance.
  • Immigration Status: Bring necessary immigration documents for each household member to verify status.
  • Health Insurance: If you or a family member has health insurance, include the insurance company's name and relevant details on the form.
  • Stay Updated: Report any changes to your personal information, such as marital status or income, immediately to avoid issues with your assistance.
  • Assistance Available: If you need help gathering documents or understanding the application process, don't hesitate to ask the interviewer for assistance.

By keeping these key points in mind, you can navigate the application process more confidently and ensure that you have the necessary resources for your financial assistance needs.