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 and Drug Replacement programs, but may not be required of other programs you may be eligible for, like Expanded Primary Health Care Program (EPHC) and other Texas Department of State Health Services programs.)
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
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.
• Other proof of marriage
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, or agency letter.
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; 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.
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
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.).
You must fill out papers for CHIP, CHIP Perinatal, Medicaid, TANF (Temporary Assistance for Needy Families), SSI (Supplemental Security Income) or Title V benefits if you can have these programs.
Texas Application for Health Coverage & Help Paying Costs
Please use the following links to download the Texas application(s) for Medicaid/CHIP.