Form 280478 (8/02)
APPLICATION FOR ASSISTANCE
HARRIS COUNTY HOSPITAL DISTRICT
Financial assistance from the Harris County Hospital District (HCHD)
helps people pay for needed medical care received at HCHD facilities.
Whether you can get this help depends on your income, where you live,
other help you receive or could receive, and other items.
You may turn in or mail back your application, even if you cannot
answer all the questions. However, if you do not answer all questions,
your application will be incomplete, and HCHD will be unable to
determine if you are eligible for financial assistance.
Try to answer as many questions as you can on this application. Be sure
• Answer all questions in Item 1, General Information, and
• Sign and date the last page of the application.
You can turn in your application to any eligibility center, or mail or fax
HCHD Financial Assistance Program
c/o Patient Eligibility Services Administration
2525 Holly Hall, Suite 200
Houston, TX 77054
Fax: (713) 566-6670
Once your application is received, you will be contacted to arrange an
appointment for an interview.
You may be asked to bring proof of what you write on your application
or tell the person interviewing you. If you need help getting proof, the
person interviewing you will help. Or, you can ask to see the manager at
the interview location.
Examples of some of the things you may be asked to prove and things
you can use for proof are:
• YOUR IDENTITY AND IDENTITY OF FAMILY MEMBERS
Possible proof: Driver’s license or Texas Identification card,
student ID with picture, employee job badge with picture,
passport with picture, U.S. Immigration documents with picture,
credit card with picture, ID issued by foreign consulates,
marriage license, birth certificates, Social Security card, U.S.
naturalization, citizenship or other federal documents, hospital
or birth records, adoption papers or records, voter’s registration
card, or wage st