"How do I apply for a discount (Gold Card)?"

1. Fill out the application
   English (pdf)
   Spanish (pdf)
    
2. Mail or fax the application to:
   
   HCHD Financial Assistance Program
   c/o Patient Eligibility Services Administration
   PO BOX 300488
   Houston, TX 77230
   Fax: (713) 566-6670
    
3. If you are a renewing patient, you can complete your renewal by mail or fax. We will contact you if further information is needed to complete your application. If you need further assistance, please call 713-566-6509.
    
4. What to mail in with your application:
   
   To establish your eligibility requirements for an HCHD Gold Card, you will need to provide proof for the following six items. By providing these six items you will help ensure your Gold Card application goes smoothly. If you are having difficulty finding or providing any of the mentioned items, refer to the alternative proof links below, or call the nearest eligibility center to ask about other documents or proofs you may submit.
   
   If you need help getting proof, the person interviewing you will help.  Below is the list of items and alternative proofs needed to process your application:

1. YOUR IDENTITY AND IDENTITY OF FAMILY MEMBERS
   
   Possible proof: Driver’s license or Texas Identification card, student ID with picture, employee job badge with picture, passport with picture, U.S. Immigration documents with picture, credit card with picture, ID issued by foreign consulates, marriage license, birth certificates, Social Security card, U.S. naturalization, citizenship or other federal documents, hospital or birth records, adoption papers or records, voter’s registration card, or wage stubs,
    
2. WHERE YOU LIVE AND PLAN TO CONTINUE LIVING
   
   You will need two proofs: one dated within the past 60 days and the other dated up to one year ago. Possible proof: utility bills; lease agreement; school records for minor children; mortgage coupon; rental verification form; Department of Motor Vehicles record; credit card statement; property tax statement; automobile insurance documents; automobile registration; printout from IRS of current tax year filing; certification documents or benefits checks from the Social Security Administration or Texas Workforce Commission; certification documents from Food Stamps, Medicaid or Medicare; letter from recognized social services agency; mail addressed to you or your spouse; statement from child care provider; current voter’s registration card; Texas driver’s license; ID card issued by the Department of public safety; domicile verification form completed by a reliable third person, post office records; city or criss-cross directory; telephone directory; or church records.
    
3. HOUSEHOLD INCOME FOR THE PAST 30 DAYS
   
   Possible proof: pay check stubs; pay checks; W-2 tax forms; wage verification letter; current year 1040 tax form; benefit letters; retirement checks or statements.
    
4. HOUSEHOLD COMPOSITION (who lives with you)
   
   Possible proof: birth certificate; baptismal record; most recent IRS 1040 form; Social Security Award letter for dependents; school documents; insurance documents; U.S. Immigration application; divorce or child support decree; baby’s Popras form, birth fact record, or hospital armband); proof of school enrollment for students aged 18-23.
    
5. IMMIGRATION STATUS
   
   You do not have to be a U.S. citizen to qualify for financial assistance. However, if you are not a citizen, and you have documentation from the INS, it must be presented to determine your eligibility for assistance.
    
6. OTHER HEALTH CARE COVERAGE
   
   Possible proof: award or claim letters; insurance policies; court document; other legal papers.
    
7. RESOURCES
   
   If you have Medicare coverage and you want to apply for a discount on services and fees not covered by Medicare, you must provide proof of your resources and liabilities.
   Fill out the Medicare Asset Determination. (pdf)

Information on race and sex is voluntary. Information on Social Security Numbers should be given if available. These types of information will not change your eligibility.

You must give information about medical insurance and other third party financially liable for medical services paid under this program for yourself and members of your household. By signing and submitting this application, you are agreeing to give HCHD the right to recover the cost of health care services provided by HCHD from any third party.

You will be asked to apply for Medicaid, TANF (Temporary Assistance for Needy Families) or SSI (Supplemental Security Income) benefits. If you are asked to apply for one of these programs, you may still be eligible for assistance from HCHD for a limited period of time. If you cooperate with the application process and your application is denied, you may continue to be eligible for assistance from HCHD.  However, if it is determined that you did not cooperate with the application process, you will no longer be eligible for assistance from HCHD.

After turning in your application, you must report within 14 days any changes in your address, income, people living with you, or application for (or receipt of) SSI, AFDC, or Medicaid. Failure to report these changes may result in losing your assistance from HCHD.

If you are qualified for financial assistance and it is later determined that the information or proof you provided on this application was false, you may lose your financial assistance, may be barred from reapplying for six months, and be required to repay HCHD for any services rendered. You may also be charged with criminal and/or civil penalties.

*Applications are in Adobe Reader (pdf) format. You must have Adobe Reader installed to view the files. You can download the application for free. Click on the button to download Adobe Reader.

Click here for the Gold Card/Eligibility Manual Policies.