REFERRAL NOTICE

Name:______________________________________________ Patient Identifier Number:_____________________________
Application Number:___________________________________ Eligibility Center:____________________________________
Plan:_______________________________________________ Expiration Date:_____________________________________
Interviewer:__________________________________________ Date:______________________________________________


Based on your income or disability, you have been referred to apply for:

 Medicaid  CHIP  Medicare
 SSI  CHIP Perinatal

Please apply to be eligible for financial assistance review.

If you are approved, please bring proof to the nearest Eligibility Center.
Please call Customer Service Department at (713) 566-6600 for the services that you have received at Harris County Hospital District, your bills will be sent to your approved healthcare plan.

If you are not approved, please drop off or mail your denial letter to the eligibility center.

If you have any questions, please call (713) 566-6509, Monday through Friday, from 8:00AM to 4:30PM.

Below is the list of Eligibility centers.

Location Address
Eligibility Correspondence Division
P.O. Box 300488
Houston, TX 77230
Acres Home Eligibility Center 818 Ringold
Houston, TX 77088
East Mount Houston Eligibility Center 11737 B Eastex Freeway
Houston, TX 77039
Southeast Eligibility Center
3550–A Swingle Road
Houston, TX 77047
Southwest Eligibility Center 8901B Boone Road
Houston, TX 77099
Strawberry Eligibility Center 925 Shaw
Pasadena, TX 77506