Download your Gold Card Application | Houston Gold Card

gold card application

Gold Card Application

Download your Gold Card Application by clicking HERE.

Note: Harris Health no longer refers to its medical coverage as Gold Card. Most still refer to  Harris Health’s medical coverage as Gold Card, however the new name is Harris Health Financial Assistance Plan.

Gold Card Documents Needed

In addition to the Gold Card Application (Harris Health Financial Assistance Plan), you will also need to supply the following documents:

Identification

Identification is needed for both you and your spouse if you’re married. This would include marriage license or Registration of Informal Marriage if you are common law.

One proof of identity is needed if you possess the following:

  • Driver license
  • Current state ID
  • Employment badge
  • US immigration documents
  • Foreign consulate ID card
  • Agency letter

If you do not have a picture form of ID you must supply two of the following:

  • Birth certificate
  • Marriage license
  • Hospital or birth records
  • Adoption paperwork
  • Harris county voter card
  • Check stub
  • Social security card
  • Medicaid card
  • Medicare care

Proof of address

You must provide a document with your address, your name or spouse’s name.

You only need one of the following if the mail is dated within the last 60 days:

  • Utility bill
  • Mortgage coupon
  • Business mail
  • School record for children under age 18
  • Certification document or benefits checks from Social Security Administration or Texas Workforce Commission
  • Certification paper from Supplemental Nutrition Assistance Program (SNAP), or SNAP From TF 0001.
  • Agency Letter
  • Statement from a licensed child care provider
  • Harris Health System-Residence Verification Form filled out by a non-related person, not living in your house.  Click HERE to download the Harris Health System Residence Verification Form.
  • Check stub
  • Credit card statement
  • Medicaid or Medicare letter

If in the last year any of these documents are acceptable:

  • Lease agreement
  • Department of motor vehicle record
  • Automobile registration
  • Property tax document
  • Automobile insurance document
  • Printout from IRS of most current year’s tax filing

Proof of income

Income for the past 30 days for you, your spouse and children living with you who are over the age of 18 is needed. Here are the acceptable documents:

  • Cash income
  • Rental property
  • Workmen’s compensation
  • Current check stubs
  • Social security award letter
  • Current IRS 1040/1040A tax return (all pages) if self-employed
  • Veteran Affairs letter or check
  • Unemployment benefit record
  • Agency letter
  • Income on SNAP from TF 0001
  • Harris Health System – Statement of Self-Employment Income Form if no tax return is filed. Click HERE for Harris Health System Self-Employment Income Form.
  • Harris Health System – Statement of Wage Verification Form (for cash and personal check wages only). Click HERE for Harris Health Wage Verification Form.
  • Harris Health System – Statement of Support Form if no income. Click HERE for Harris Health System Statement of Support Form.

Proof of relation to children 

The following document (only one) is needed for any children living with you who depend on you for support:

  • Birth certificate
  • Proof of full-time school enrollment for students aged 18-26
  • US immigration applications with dependent’s names
  • Death certificate for previous household members
  • School documents or insurance documents showing names of both parent and child
  • Birth fact record or hospital armband for infants less than 90 days old
  • US Department of Health and Human Services – Office of REgugee Resettlement – Verification or Release Form ((ORR UAC/R-1) for an Unaccompanied alien child.
  • Baptismal record
  • Social Security award letter with dependent’s names
  • Baby’s Popras forms

Immigration status

You must show current or expired documents from the US Citizenship and Immigration Services for you, your spouse or children who depend on you for support.

Health Care Coverage (if applicable) 

You must show proof of Medicaid, CHIP, CHIP Perinatal, Medicare, or private health insurance for you, your spouse or children who depend on you for support.

If you have Medicare

Complete the Medicare Asset From. This form shows proof of your current resources (bank statements, credit cards, etc). Download your Medicare Asset Form HERE.

Where Can You Drop Off Your Gold Card Application?

Read our article  How To Apply For Harris Health(Gold Card)? for a complete listing of clinics that you can drop your Gold Card Application off at.

Where Can I Mail My Gold Card Application?

If you prefer to mail your Gold Card Application, send it to the following address:

Harris Health Financial Assistance Program
P.O. Box 300488
Houston, TX 77230
713- 566- 6509

Other Articles Of Interest

How To Apply For Harris Health (Gold Card)?

Harris Health Same Day Clinics

 

 

 

 

Nick Bryant is a Counselor with 10 years of experience working in community health. He enjoys concerts, mocking Dallas Cowboy fans and creating easy to understand community resources on his site HoustonCaseManagers.com. To become a more saucy social worker, hop on his free email list and receive weekly community resource guides delivered directly to your inbox.