HCHD 283117 2010-2024 free printable template

Video instructions and help with filling out and completing gold card application

Instructions and Help about harris health gold card application form

Put your name in this field now put your unmarried name if you're married in this field this is the field for your street address where you receive bills in this field you should put your apartment number for the place that you live in this Bill's right your County which for most people will be Harris in this field right your city which for most people will be Houston here you should write TX for Texas the state you live in here you should write your zip code you should look at a bill that has been sent recently to your home and look for this five-digit number somewhere on that bill here write your home telephone number which for most people are a cell phone if you have a phone number where you can be reached at work write it here, but many people will not have anything to put here you may specify your marital status as single married separated divorced widowed or common-law next specify whether you've been to bend tub Quinton main or LBJ hospitals by marking yes or no here if you happen to one of these hospitals then write the date here in this table enter the names of all the members of your household start by entering people's last names in the column here you should enter the first names of your family members in this column here you should specify the relationship for example father brother and uncle sister or mother enter the date of birth of each of your family members in this column now write the social security number of each family member in this column here you should enter the race of each family member for example Burmese Nepalese Congolese Iraqi and a richer Ian here you should specify the gender of each family member either select male or female in this column next select whether each member of your family is employed by selecting yes or no in this column next specify the legal status of each member in your home this may be citizen legal resident which is common for many refugees undocumented worker work permit worker sponsored or visa which is also common for many refugees in this table you should enter the names of people in your home who work start by entering their name in this column then specify the company that they work for and how often they get paid for example bi-weekly twice monthly or monthly and then enter the amount that they get paid here is anyone in your home pregnant if so mark yes and if not mark know if someone is pregnant in your home, and you marked yes then put their name and the expected delivery date in this field is anyone in your home in sure if so mark yes and if not mark know if you marked yes and someone has health insurance write their name here and then write the name of the company and the member number here finally you should complete the application by signing in this field and then writing today's date in this field