NOTIFICATION OF DENIAL/DECLINE FOR FINANCIAL ASSISTANCE
Name:________________________________________________ Patient Identifier Number:_______________________________
Application Number:_____________________________________ Eligibility Center:______________________________________
Interviewer:____________________________________________ Date Denied/Declined:_________________________________
Your financial assistance application has been denied/declined because:
__________ You are not a resident of Harris County, Texas.
__________ Harris County Hospital District (HCHD) is not contracted with your Health Maintenance Organization
(HMO) or insurance plan.
__________ You have selected a Primary Care Provider (PCP) that is not in Harris County Hospital District’s
network.
__________ Your income exceeds the limit for financial assistance.
__________ Your assets exceed the limit for financial assistance.
__________ You did not return the items necessary to complete your application within the specified timeframe.
__________ You voluntarily declined financial assistance.
__________ Other (specify) __________________________________________________________________
______________________________________________________________________________________
You can see the doctors at the Harris County Hospital District, but you will be expected to pay 100% of all charges.
You may re-apply for financial assistance any time your status changes. You may ask for copies of our financial assistance policies at any eligibility location. If you do not agree with the financial assistance denial above, please ask to speak to the Eligibility manager or file an appeal using the section below. You may also file an appeal to the County Court of Harris County, Texas.
APPEAL SECTION
Please mail or fax within 65 days from the date of this letter to:
Mail to: Appeals Committee
Harris County Hospital District
P.O. Box 300488
Houston, TX 77230-0488
Fax to: (713) 566-6525
I am appealing because: _____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Patient’s Signature: _______________________________________Date: _____________________________________
