NOTIFICATION OF FINANCIAL ASSISTANCE CLASSIFICATION AND RIGHT TO REQUEST APPEAL

Name: _____________________________________________ Patient Identifier Number: _____________________________
Application Number: __________________________________ Eligibility Center: ____________________________________
Plan: ______________________________________________ Eligibility Expiration Date: _____________________________
Interviewer Name: ___________________________________ Date: _____________________________________________


You have been approved for financial assistance with the plan listed above.

If you have Medicaid, Medicare, CHIP, CHIP Perinatal, or any other healthcare coverage, part or all of your medical bills will be paid by them. Please bring your current insurance card with you to each clinic visit.

You must report within 14 days any change in name, address, marital status, legal status, income, household members, healthcare insurance, pending for Medicaid, SSI or CHIP. If you do not report these changes, your financial assistance may be cancelled. You can take your proof of change to the nearest eligibility center or mail to:

Patient Eligibility Administration
Harris County Hospital District
P.O. Box 300488
Houston, TX 77230

If you or your dependents were required to apply for Medicaid, Medicare, SSI, CHIP or CHIP Perinatal, please follow through with the application process. If you or your dependents do not apply for benefits, you may lose your financial assistance.


If you do not agree with your financial assistance plan, 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. You may ask for copies of financial assistance policies at any Eligibility location.



APPEAL SECTION

Please mail or fax within 65 days from the date of this letter to:

Appeals Committee
Harris County Hospital District
P.O. Box 300488
Houston, TX 77230-0488
Fax: (713) 566-6525

I am appealing because: ________________________________________________________________________________________________________

________________________________________________________________________________________________________

Patient’s Signature: ___________________________________________________ Date: _______________________________







RECEIVING HEALTH CARE FROM HCHD
Your Community Health Center for outpatient care is __________________________. For emergency services and hospital admittance, your hospital is _______________________________. Be sure to make and keep appointments at your community health center because that is where your doctor and medical records will be located.

Eligibility Centers (Gold Card)
Please contact (713) 566-6509 to schedule eligibility appointments.
Please contact (713) 526-4243 to schedule clinic
appointments.