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Obtain a copy of the application for a Gold Card from the Harris County Hospital District Financial Assistance Program offices or from the HCHD website (hchdonline.com).
Provide your name, maiden name -- if applicable -- address, phone number and marital status. List the name, age, date of birth, Social Security number, sex, race, employment status and legal status of every person living in your home, including yourself.
List the names of each person in your household with a paying job, employer names, income and the frequency of pay periods for each job.
Answer questions and provide information about whether or not anyone in your household is pregnant, the expected due date, whether or not anyone has medical insurance and with whom, if anyone receives Social Security Income and whether or not anyone is unemployed.
Sign and date the
application in the presence of a witness. Make copies of your and your spouse's photo identification, immigration paperwork (such as green cards or alien registration numbers), health care policies for anyone in your household with medical insurance, Medicare information, birth certificates for each of your children, income tax returns, pay stubs for the past month and W2 forms and proof of your residency. To prove your residency you may use your mortgage statement, rental contract, apartment lease, utility bills or financial statements showing your name and current address.
Take or mail your application and supporting documents to:
HCHD Financial Assistance Program
PO Box 300488
Houston, TX 77230
Once your application is reviewed an appointment is scheduled for you to meet with a HCHD employee to discuss your application. You are notified by mail if and when you are approved for a Gold Card.