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I LOST MY MEDICAL CARD AND NEED TO GO TO HOSPITAL REGISTRATION
I LOST MY MEDICAL CARD AND NEED TO GO TO HOSPITAL FREE

Both parties should date and sign on the form.Īnd you need a copy of one proof with a picture on it: State issued driver's license, state issued ID card, current student ID, current employee job badge, passport with picture, U.S. If you declare common law/informal marriage on the application and do not have DSHS Form VS-180.1, please download, print THHSC Form H1057 and complete it. If you declare common law/informal marriage on the application and have DSHS Form VS-180.1, this form will be accepted as a proof of marriage.

I LOST MY MEDICAL CARD AND NEED TO GO TO HOSPITAL REGISTRATION

Declaration and Registration of Informal Marriage if common lawĪ.

Identification for you and your husband or wife

I LOST MY MEDICAL CARD AND NEED TO GO TO HOSPITAL FREE

You will be asked to sign the Medication Assistance Program (MAP) Consent and Authorization Form (Form #283233) that tells Harris Health to share your personal health information and sign any forms that are needed for you to get free medicine.ġ. Harris Health's pharmacy staff can sign you up for patient assistance programs to get free medicines from drug companies. Please make and give Harris Health copies of the following papers with your application (This information, papers and signatures are required for Harris Health Financial Assistance, Drug Replacement programs and some federal grants.) APPEALS PROCESS If you disagree with the eligibility determination stated on the Harris Health System Notice you received, please complete an appeals form ( English, Spanish, Vietnamese) and mail within 65 calendar days from the date of your notice to:Įligibility Appeals Committee Harris Health System P.O. If you have any questions, call the Eligibility Call Center at 71.

(Third Wednesday of the month, open 7:30-11 a.m.) (Fourth Thursday of the month, open 7 a.m.-noon) (Second Wednesday of the month, open 8 a.m.-noon) (Fourth Thursday of the month, open 7-11 a.m.) d. Drop-off your completed application and proof documents in the eligibility drop box at the following locations at the front door of each health center. c. Complete all sections on your application and attach proof documents. Drop-off a. Click on your preferred language to open the application ( English, Spanish, Vietnamese).d. Complete all sections on your application and attach your proof documents. b. Click on your preferred language to open the application ( English, Spanish, Vietnamese ) c. Print the application. 5) Patients who need to have a prescription filled or renewed in which Harris Health medical staff wrote. 4) Patients who need to schedule or reschedule a Harris Health medical appointment or a procedure. 3) Patients who have a surgical procedure scheduled at a Harris Health facility. Johnson hospital’s emergency room within the past 30 days and need a follow-up appointment. 2) Patients discharged from Ben Taub or Lyndon B. Johnson hospitals within the past 30 days and need a follow-up appointment. Expedite cases/Fast track eligibility application a. You must fall into one of the categories described below to apply at one of the health centers listed below (in the Drop off section) 1) Patients discharged from Ben Taub or Lyndon B.d. Mail your completed application to: Harris Health Financial Assistance Program P.O. Apply by mail a. Click on your preferred language to open the application ( English, Spanish, Vietnamese).You cannot use it to apply by mail or drop off. e. The online application is for electronic submissions only, using the link above. d. Complete all sections on the application and upload your proof documents.

c. Click on the following link to find Harris Health’s Financial Assistance Application, along with instructions for the application process. b. If you have a Harris Health System medical record number, please have it available. A Harris Health System medical record number is not required to complete the online application. Apply online a. Please use one of the following web browsers to complete the online application: Google Chrome, Microsoft Edge, or Safari.For your convenience, you have several options to apply for Harris Health’s Financial Assistance Program. Harris Health does not provide health insurance coverage under the Federal Health Insurance Marketplace Exchange. Harris Health System’s Financial Assistance Program is not an insurance plan. Proposed Budget, Tax Rate & Hearing Notices.Ambulatory Surgical Center (ASC) at LBJ Governing Body.