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:
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.
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.
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.
Nick Bryant is the author of Understanding Healthcare Is Half The Battle and a Senior Counselor with 13+ years of experience working in community health and mental health. He enjoys spending time with his family, watching WWE on Friday nights, and working toward a Google Data Analytics certification. If you have additional questions about community resources or government assistance programs, simply leave a comment below and he will follow up as soon as possible.