Harris health gold card application pdf download
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This article will provide you with a Gold Card application and the list of documents (proof of income, residence, etc) needed to apply for Gold Card Download the Gold Card application. This document must be secured at all times while in use and must be immediately disposed of in the blue recycling bin when you are done using the document. It will help you cover some of the costs of hospital visits when you go to hospitals and clinics in WAGE VERIFICATION FORM. Begin scheduling medical appointments with your Gold Card by calling the appointment line at Also find a list of additional documents needed to apply. Find a Harris Health eligibility center. The Harris Health Financial Assistance Program is for patients living in Harris County. You must provide information about yourself, your household income, your Harris Health System Medical Record Number, and any changes you have had since your last Harris Health System enrollment. The fourth Friday of the month,a.m p.m TF; (16) Harris Health System-Statement of Self Employment Income Form if no tax return is filed; (17) Harris Health System-Wage Verification Form (for cash and personal check wages only); and (18) Harris Health System-Statement of Support Form, if no incomeAddress with your name or your spouse’s name New Application. Printed copies of this document are uncontrolled. Send Documents Download a Gold Card application to apply for coverage via Harris Health. FOR EMPLOYER. Gather the supporting documents needed. In the case of a conflict betweenIf you have questions regarding eligibility and how to apply, renew or obtain the status of your application, call the Eligibility Call Center at The call center is available Monday-Friday,a.m p.m. If you are How To Get Your Harris Health Plan. Your employee or his/her family member has applied for assistance at Harris Health System. There is no cost to make a Harris Health Financial Assistance Application. There is no cost to make a Harris Health Financial Assistance Application. Apply Here. Wait for your Gold Card to be processed. We need to verify his/her gross Monthly Income Estimate. If you are asked to pay, please call Fill out the The Gold Card is a financial assistance program by the Harris County Health System. This document contains protected and confidential patient health information.