Download Your Gold Card Application

gold card application

Download your Gold Card Application | Houston Gold Card


In this article, you will find a link to download your Harris Health Gold Card application.

Download Your Gold Card Application HERE ↓↓

Download your English Gold Card Application PDF by clicking HERE.

For a Gold Card application in Spanish go here.

Here you can download a Vietnamese application.

Editor’s note: Harris Health no longer refers to its medical coverage as a 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:

1. Identification

Identification is needed for both you and your spouse if you’re married. This would include a 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
  • A 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

2. Proof of address

You must provide a document with your address, your name, or your 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
  • The school record for children under age 18
  • Certification document or benefits check 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

3. 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
  • A 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 the 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.

4. 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 the 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 Refugee 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

5. 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.

6. 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.

7. 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.

download gold card

Where To Drop Off Your Gold Card Application?

You can drop off your Harris Health Gold Card Application at any of the Harris Health Eligibility Centers.

The map below pinpoints where each office is located.

Where Can I Mail My Gold Card Application?

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

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

Gold Card Renewal Form

The Gold Card renewal form is the same exact form as the regular application. When your Harris Health Gold Card is 30 days from expiring you will need to complete the same form you did when you first applied to renew your coverage. 

Other Articles Of Interest

For step-by-step instructions on applying for Gold Card see our guide titled How To Apply For Harris Health (Gold Card).

If you already have Gold Card and need to find a same-day clinic for minor illnesses refer to our guide titled Harris Health Same Day Clinics.

Conclusion 

If you are denied Medicaid, Harris Health / Gold Card can serve as an adequate alternative.

The first step in applying for coverage is completing a Harris County Gold Card application. Below are links to both English and Spanish applications:

Once you’ve completed your application the next step is finding a Harris Health Eligibility Center to drop off your documents.

The process is that simple although if you have questions comment below or call Harris Health at 713- 566- 6509. 

12 thoughts on “Download Your Gold Card Application

  1. Louis Reply

    How can I get Harris county gold card application approved immediately due to medical emergency?

  2. Nick Bryant Post authorReply

    Hi Louis, typically if you are hospitalized they will speed up the process for a Gold Card. Short of that you’ll want to have all the documents required and then visit a Harris Health System eligibility center (see the map above). The thing that delays most Gold Card applications is missing documents (income, residency, dependents birth certificates, etc). Long story short I’m not sure if they immediately approve gold card applications for people who are not hospitalized but the eligibility line 713.566.6509 can definitely provide a definitive answer. Let me know how it turns out and good luck my man.

    • Cynthia Collins Reply

      I have tried several times to complete an online application and I’m unsuccessful. Please tell me the steps to take to apply for a gold card.

      Desparately Seeking Coverage

  3. Shirley Clary-Pura Reply

    Can you someone get a Gold Card if they have no proof of immigration documentation. Patient has cancer and needs help. The patient resides in Houston Texas.

    • Nick Bryant Post authorReply

      Hi Shirley, a lack of paperwork is something that slows lots of people up in obtaining Gold Card. I think your best bet is to call Harris Health at 713.566.6509 to learn about alternative documents if they don’t have the immigration paperwork.

      Another option is using the link below to find Federally Qualified Health Centers near your client’s home. These are clinics that receive government funding and patients do not need health insurance for help.

      Hope Clinic is one and I believe they provide Oncology services at their clinic. Most of their locations are in SW Houston https://www.hopechc.org/. San Jose Clinic is another good option and they specialize in helping the Hispanic community. They are located in Midtown of McGowen https://www.sanjoseclinic.org/

      Despite the option I just named your best bet is trying to work with Harris Health for the Gold Card though because they have a lot more resources available for indigent patients with something like cancer.

  4. Victor Manuel rauda Reply

    how can I find out the status of an application filled 2 weeks ago processon line

    • Nick Bryant Post authorReply

      Hey Victor, eligibility line…713.566.6509…may be able to help.

      If you cant get anyone on the phone w eligibility line, call the appointment line instead…713-526-4243…they’ll ask for your name and DOB. If your information isn’t in the system yet they’ll let you know and may even have a way to check to see if any documents are missing.

  5. sabah Reply

    i am living with someone who lives in harris county ,i am renting a room,i don’t have utility bill under my name can i apply for gold card,what kind of documents will i be needing?

    • Nick Bryant Post authorReply

      Hi Sabah, you just need to prove to them that you live in Harris County. If you do not have a utility bill, what about any other bills that come to that address in your name?

      Harris Health System outlines all the acceptable documents in the link below so definitely check it out:

      https://www.harrishealth.org/access-care/patient-eligibility#tabGroup12

      Again if you can find mail in your name with that Harris County address you should be good. To be on the safe side call the Health System phone number at 713.566.6509 to confirm what documents they are willing to accept as an alternative to that utility bill.

      Best of luck Sabah and Happy Thanksgiving!

      Nick

  6. paula Reply

    Hi Nick,
    My question refers to the people over 18. My husband and I pay rent and live with his 67 year old mother. Does she need to sign anything? She is retired and receives social security, Thank you In advance.
    Paula

    • Nick Bryant Post authorReply

      Hi Paula, hope all is well with you.

      The application does require the information for all household members and sources of income for everyone in the household, however, I’m not sure that she would have to sign anything.

      The only way that she may have to sign something is if you are not working and she is supporting you. There is a supporter statement that family members complete when the person applying for Gold Card does not have an income.

      To be on the safe side contact the Harris Health Eligibility Line at 713.566.6509 to go over your situation, because I don’t want to misguide you.

      Hope that helps you my friend!

      Nick

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