Harris Health Gold Card Supporter Statement

In this community resource, you will learn about the Harris Health Support Statement document and what it is used for. 

Harris Health System offers a Gold Card for those who have zero income and require financial assistance to obtain quality health care services. In order to qualify, for Gold Card you will need to show some type of proof of income. If you do not have a monthly income, you can satisfy this need for proof of income by completing a document called a  “Statement of Support”.  

Continue reading to learn what this document is and who should complete a Gold Card supporter statement. 

What is the Harris Health System Statement of Support Document?

The Statement of Support is a Harris Health document that is required to be filled out by someone who is supporting an individual with a $0 income. The form includes details such as the name of the client, the supporter’s name, the supporter’s relationship with the client, and the source of income and duration of support. The form also indicates the type of support given and the amount of financial assistance offered.

What are the different types of support?

The form provides several options for supporters to select from when indicating the type of support they are providing, including:

• Giving room and board
• Giving money regularly
• Paying household expenses directly to the company
• Other support, with an explanation

Download A Harris Health Gold Card Supporter Statement 

You can download a Harris Health Statment of Support by using the links below: 

• English Supporter Statement
• Spanish Supporter Statement
• Vietnamese Supporter Statement

The picture below is what the Supporter Statement looks like. On the form, you (or a family member) will state whether you are providing a place to stay for the client, a source of income each week/month, and what your relationship is with the client.  

Who Should Complet A Supporter Statement?

The Gold Card Eligibility Supporter statement is for individuals who have a $0 monthly income and are living with a family member or friend who is helping them financially. In addition, if you are unemployed, just moved to Houston and living with someone or in any other situation where you do not have a monthly income. 

To apply for Harris Health Gold Card you must show proof of income. If you are not working, then Supporter Statement is the document that is used to show your proof of income. 

Who is eligible for a Harris Health Gold Card?

The Harris Health Gold Card is designed to help individuals who have $0 income and are not eligible for Medicaid, Medicare, or any other insurance plan. To qualify, individuals must provide proof of Harris County residency, income, and identification.

You can still visit a Harris Health clinic if you have health insurance because they accept multiple plans. 

How can I apply for a Harris Health Gold Card?

To apply for a Harris Health Gold Card, individuals can submit an application either online or in person.

The application requires information about the client’s income, expenses, residency, and identification. Once the application is reviewed and processed, the client will receive a determination of eligibility, which can take up to 30 days.

How can I get help filling out the Statement of Support?

If you require assistance filling out the Statement of Support, Harris Health System provides customer service representatives to help you through the process. Call the Harris Health eligibility center phone line at 713.566.6509 to ask questions about the Supporter Statement. 

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