Patient Eligibility

Harris Health System’s Financial Assistance Program is not an insurance plan. Harris Health does not provide health insurance coverage under the Federal Health Insurance Marketplace Exchange.
 
For your convenience, you have several options to apply for Harris Health’s Financial Assistance Program.

1. Apply online
   a. Please use one of the following web browsers to complete the online application: Google Chrome, Microsoft Edge, or Safari.
   b. If you have a Harris Health System medical record number, please have it available. A Harris Health System medical record number is not required to complete the online application.
   c. Click on the following link https://ola.veritysource.com/harris to find Harris Health’s Financial Assistance Application, along with instructions for the application process.
   d. Complete all sections on the application and upload your proof documents.
   e. The online application is for electronic submissions only, using the link above. You cannot use it to apply by mail or drop off.
   ​​​​
2. Apply by mail
   a. Click on your preferred language to open the application (English, Spanish, Vietnamese). 
   b. Print the application.
   c. Complete all sections on your application and attach proof documents.
   d. Mail your completed application to:
   Harris Health Financial Assistance Program
   P.O. Box 300488
   Houston, TX, 77230
   
   
3. Expedite cases/Fast track eligibility application
   a. You must fall into one of the categories described below to apply at one of the health centers listed below (in the Drop off section)
   1) Patients discharged from Ben Taub or Lyndon B. Johnson hospitals within the past 30 days and need a follow-up appointment.
   2) Patients discharged from Ben Taub or Lyndon B. Johnson hospital’s emergency room within the past 30 days and need a follow-up appointment.
   3) Patients who have a surgical procedure scheduled at a Harris Health facility.
   4) Patients who need to schedule or reschedule a Harris Health medical appointment or a procedure.
   5) Patients who need to have a prescription filled or renewed in which Harris Health medical staff wrote.
   b. Click on your preferred language to open the application (English, Spanish, Vietnamese)
   c. Print the application.
   d. Complete all sections on your application and attach your proof documents.​
   
   
4. Drop-off
   a. Click on your preferred language to open the application (English, Spanish, Vietnamese).
   b. Print the application.
   c. Complete all sections on your application and attach proof documents.
   d. Drop-off your completed application and proof documents in the eligibility drop box at the following locations at the front door of each health center.
   

   Drop-off Locations	​Address	​Hours of Operation
   ​Acres Home Health Center	​818 Ringold Houston, TX, 77088	​Monday-Friday:  8 a.m.-5 p.m. (Fourth Thursday of the month, open 8 a.m.-noon)
   ​El Franco Lee Health Center	​8901 Boone Road Houston, TX 77099	​Monday-Friday: 8 a.m.-5 p.m.  (Second Wednesday of the month, open 8 a.m.-noon)
   ​Martin Luther King Jr. Health Center Eligibility Service Center	​3550 Swingle Road Houston, TX 77047  3550-A Swingle Road Houston, TX 777047	​Monday-Friday: 7 a.m.-4 p.m. (Fourth Thursday of the month, open 7 a.m.-noon)
   ​Strawberry Health Center	​927 Shaw Ave Pasadena, TX 77506	​Monday-Friday: 7:30 a.m.-5 p.m. (Third Wednesday of the month, open 7:30-11 a.m.)

   
   

If you have any questions, call the Eligibility Call Center at 713-566-6509. 
 
APPEALS PROCESS
If you disagree with the eligibility determination stated on the Harris Health System Notice you received, please complete an appeals form (English, Spanish, Vietnamese) and mail within 65 calendar days from the date of your notice to:

Eligibility Appeals Committee
Harris Health System
P.O. Box 300488
Houston, TX 77230

Please make and give Harris Health copies of the following papers with your application (This information, papers and signatures are required for Harris Health Financial Assistance, Drug Replacement programs and some federal grants.)

Harris Health's pharmacy staff can sign you up for patient assistance programs to get free medicines from drug companies. You will be asked to sign the Medication Assistance Program (MAP) Consent and Authorization Form (Form #283233) that tells Harris Health to share your personal health information and sign any forms that are needed for you to get free medicine.

1. Identification for you and your husband or wife

• Marriage license/IRS1040 if married
• Declaration and Registration of Informal Marriage if common law
• Other proof of marriage 

a. If you declare common law/informal marriage on the application and have DSHS Form VS-180.1​, this form will be accepted as a proof of marriage.
b. If you declare common law/informal marriage on the application and do not have DSHS Form VS-180.1, please download, print THHSC Form H1057​ and complete it. Both parties should date and sign on the form.

And you need a copy of one proof with a picture on it:
State issued driver's license, state issued ID card, current student ID, current employee job badge, passport with picture, U.S. immigration documents, foreign consulate ID card, agency letter, or current enhanced+ public library photo ID card.

If you do not have a picture ID, you need a copy of two proofs:
Birth certificate (not for married women), marriage license or Declaration and Registration of Informal Marriage, social security card, other federal document showing your name and address in Harris County, hospital or birth records, adoption papers or records, current Harris County voter card, current check stub, Medicare card or Medicaid card.

2. Address with your name or your husband or wife’s name
You need a copy of one proof dated within the last 60 days:
Utility bill; check stub; school record for children under the age of 18; mortgage coupon; credit card statement; certification documents or benefit checks from Social Security Administration or Texas Workforce Commission; certification documents from Supplemental Nutrition Assistance Program (SNAP), or SNAP Form TF0001; letter from agency or Harris Health System Agency Letter; Medicaid or Medicare letter; letter from recognized social services agency; business mail; statement from a licensed child care provider; or Harris Health System Residence Verification Form (English, Spanish, Vietnamese) completed by a non-related person not living in the your house.  

OR

You need a copy of one proof dated within the last year:
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 for the past 30 days for you, your husband or wife and children over the age of 18 who are living with you. As a new requirement for completion of your Harris Health Eligibility, every household member over the age of 18 must sign and date on the application to allow Harris health to check TWC information. 
Cash income, dividends and royalties, rental property, alimony, workmen's compensation, military pay and allowances, 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 is 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 on SNAP form TF0001, unemployment benefit records or Harris Health System Statement of Support Form (English, Spanish, Vietnamese) if no income.

4. Proof of how you are related to the children living with you who depend on you for support:
Birth certificate, baptismal record, proof of full time school enrollment for students ages 18 to 26, Social Security award letter with dependents' names, school documents or insurance documents showing names of both parent and child, 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 less than 90 days old, death certificate for previous household members, or U.S. Department of Health and Human Services - Office of Refugee Resettlement-Verification of Release Form (ORR UAC/R-1) for Unaccompanied alien child.

5. Immigration status for you, your husband or wife and all your children who depend on you for support:
You must show current or expired documents from the U.S. Citizenship and Immigration Services.

6. Health care coverage for you, your husband or wife and all your children who depend on you for support:
Please show current proof of Medicaid, CHIP, CHIP Perinatal, Medicare or health insurance.

7. If you have Medicare and are eligible for Harris health System Financial Assistance Program:
You must fill out a Medicare Asset Form (English, Spanish, Vietnamese) and show proof of your current resources and liabilities (all pages of bank statements, credit card bills, loans, etc.).

8. You must fill out papers for programs such as but not limited to CHIP, CHIP Perinatal, Medicaid, TANF (Temporary Assistance for Needy Families), SSI (Supplemental Security Income), Title V or Healthy Texas Women Program (HTWP) if you can have these programs.

You may drop off your completed application along with verification proofs at one of the following locations.  

​5.02 Financial Assistance Program

Use this tool to see which Harris Health Discount Plan you may get.

Please answer the three questions below and type your gross monthly household income in the last blank. Gross monthly household income is all the money that all household members get before any deductions.

To get your gross monthly income, if you are not paid monthly:
• Paid weekly: gross income times 4.33.
• Paid every other week: gross income times 2.17.
• Paid twice a month: gross income times 2.
• Paid yearly: gross income divided by 12.

If you have Medicare, you must fill out a Medicare Asset Form and show proof of your current resources and liabilities.