Patient Eligibility Services
Policy Manual for Eligibility 

1.0 General Policies

Last Date Reviewed

1.01

Receipt and Processing of Applications

10/24/05

1.02

Prioritization of Clients Seeking Eligibility Services

8/1/02

1.03

Retroactive Application for Financial Assistance

2/23/07

1.04

Communication to Patient Regarding Financial Assistance Determination

10/24/05

1.05

Duration of Financial Assistance Classification

8/26/05

1.07

Appeal of Financial Classification Determination

8/26/05

1.08

Records Retention

8/1/02

1.10

Confidentiality of Patient Eligibility Information

8/1/02

1.20

Provision of Public Notice and Release of Eligibility Information

8/1/02

1.30

Eligibility Education and Training

8/1/02

1.40

Eligibility Audit Function

8/23/05

1.42

Revocation of Eligibility Discount

8/1/02

1.43

Personal Attestation of Eligibility Documents

8/6/02

2.0 – Identification

Last Date Reviewed

2.01

Providing Proof of Identity

3/4/09

3.0 – Residency

Last Date Reviewed

3.01

Verifying Harris County Residency

8/1/02

3.10

Ineligible Residents

8/26/05

4.0 – Household Composition

Last Date Reviewed

4.01

Verifying Household Composition

2/23/07

5.0 – Income

Last Date Reviewed

5.01

Overview of Income Requirements

8/1/02

5.10

Verifying Income

8/26/05

6.0 – Third Party Resources

Last Date Reviewed

6.01

Applying for Third Party Resources

8/26/05 

Forms

Last Date Reviewed

E1411

Center Error Assessment Log

8/15/05

E1410

Audit Summary Report

8/15/05 

E4201

Referral for Inquiry

7/31/05 

280150

Daily Work Log (electronically generated daily)

280004

HCHD Wage Verification Form

9/1/03

280478

Application for Financial Assistance (English)
Application for Financial Assistance (Spanish)

12/2009

E1000

HCHD Payment Schedule

03/1/08

E1005

Notification of Denial for Financial Assistance

5/31/04

E1010

Receipt of Application

7/30/02 

E1071

Notice of Financial Assistance Classification and Right to Appeal

12/2009

E1100

Notification of Pending Eligibility Status

12/2009

E3000

Domicile Verification Form

7/30/02

E8100

Application for Eligibility Checklist

6/1/05