RECEIPT OF APPLICATION

Thank you for completing the application. Please provide copies of the paper(s) checked below:

________ Identification (ID) (one for you and one for your spouse)
State issued driver’s license, state issued ID card, current student ID with picture, current employee job badge with picture, passport with picture, U.S. Immigration documents with picture, credit card with picture, foreign consulate ID card with picture. If picture ID is not available, two of the following proofs may be used: birth certificate (not for married women), marriage license, social security card, other federal documents showing identity, hospital or birth records, adoption papers or records, voter’s registration card, current wage stubs, Medicare card or current Medicaid.

_________ Address
One proof of address that shows your name or your spouse’s name dated within the last 60 days:
Utility bills, school record for children under age 18, mortgage coupon, credit card statement, printout from IRS of most current year’s tax filing, certification documents or benefit checks from Social Security Administration or Texas Workforce Commission, certification documents from SNAP (Supplemental Nutrition Assistance Program, formerly known as food stamp), Medicaid or Medicare, letter from recognized social services agency, business mail, statement from a licensed child care provider, Harris County Hospital District Residence Verification Form completed by a reliable person not living in the same household or Harris County Hospital District Rental Verification Form completed by landlord.
OR
One proof of address that shows your name or your spouse’s name dated within the past year:
Current lease agreements, department of motor vehicles record, property tax documents, automobile insurance documents (non expired), automobile registration or voter’s registration card for current year.

_______ Income for the past 30 days of each household member
Current check stubs, child supports, current IRS 1040 tax return, Harris County Hospital District Statement of Self Employment Income Form, Harris County Hospital District Wage Verification Form, Social Security, Retirement, Veteran Affairs letter or check, unemployment benefit records or Harris County Hospital District Statement of Support Form if no income.

________ Household members (for each household member)
Birth certificate, baptismal record, proof of full time school enrollment for students aged 18 to 23, Social Security Award letter with dependent’s names, school documents or insurance documents showing names of parent and child, U.S. Immigration applications with dependents’ names, divorce or child support decree, baby’s Popras form ,birth fact record or hospital armband for infants under 90 days old ,current Medicaid or Death Certificate for previous household members.

_______ Immigration Status (for each household member)
You must bring documents from the U.S. Citizenship and Immigration Services.

_______ Health Care Coverage (for each household member)
Please bring current proof of Medicaid, CHIP, CHIP Perinatal, Medicare or health insurance.

________ Resources for Medicare patients
You must provide proof of your resources and liabilities (current bank statement, credit card bills, loans, etc.) on a Medicare Asset Form.

You can take your proofs to the nearest eligibility center or mail to:
Eligibility and Registration Services
P.O. Box 300488
Houston, TX 77230
____________________________________________________________________________________________________________
If you have any questions about the status of your application, please feel free to call 713-566-6509.

Applicant’s Name:_____________________________________________________________________________________________

Patient Identifier Number:_______________________________________________________________________________________

Interviewer Name:_____________________________________________________________________________________________

Application Number:___________________________________________________________________________________________

Received Date:_______________________________________________________________________________________________