1. HOW TO GET A GOLD
CARD
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2. Am I Eligible?
• You must be a Harris County resident
• Anyone is eligible regardless of age, income, or
immigration status.

3. Gather Copies of Documentation Needed
1. Identification for you and your spouse. Choose one below (for each
household member):
• A copy of one proof with a picture on it: State issued driver's license, state issued ID card,
current student ID, current employee job badge, passport with picture, U.S. Immigration
documents, or foreign consulate ID card.
• OR If you do not have a picture ID, you need a copy of two proofs: Birth certificate (not for
married women), marriage license, social security card, other federal document showing
your name and address in Harris County, hospital or birth records, adoption papers or
records, current Harris County voter card, current check stub, Medicare card or Medicaid
card.
2. Address with your name or spouse’s name. Choose one below:
• You need a copy of one proof dated within the last 60 days: Utility bill; check stub; school
record for children under the age of 18; mortgage coupon; credit card statement;
certification documents or benefit checks from Social Security Administration or Texas
Workforce Commission; certification documents from Supplemental Nutrition Assistance
Program (SNAP), formerly known as food stamp program), Medicaid or Medicare letter;
letter from recognized social services agency; business mail; statement from a licensed
child care provider; or Harris Health System Residence Verification Form (English,
Spanish, Vietnamese) completed by a non-related person not living in the your house.
• OR You need a copy of one proof dated within the last year: Lease agreement,
department of motor vehicles record, property tax document, automobile insurance
documents, automobile registration, Harris County voter card, printout from IRS of most
current year's tax filing.

4. 3. Gross income for the past 30 days for you, your spouse and
children over the age of 18 who are living with you. Choose one
below:
• Cash income, dividends and royalties, rental property, alimony, workmen's
compensation, military pay and allowances, current check stubs, child support
documents, current IRS 1040/1040A tax return (all pages).
• OR if self-employed, Harris Health System Statement of Self Employment
Income Form (English, Spanish, Vietnamese)
• OR if no tax return is filed, Harris Health System Wage Verification Form
(English, Spanish, Vietnamese) (for cash and personal check wages only),
Social Security award letter, Retirement award letter, Veteran Affairs letter or
check, unemployment benefit records or Harris Health System Statement of
Support Form (English, Spanish, Vietnamese) if no income.
4. Proof of how you are related to the children living with you who
depend on you for support. Choose one below:
• Birth certificate, baptismal record, proof of full time school enrollment for
students ages 18 to 26, Social Security award letter with dependents' names,
school documents or insurance documents showing names of both parent
and child, U.S. Immigration applications with dependents' names, divorce
decree or child support documents, baby's Popras form, birth fact record or
hospital armband for infants less than 90 days old, or death certificate for
previous household members.

5. 5. Immigration status for you, your husband or wife and all your
children who depend on you for support. Choose one below:
• You must show current or expired documents from the U.S.
Citizenship and Immigration Services.
6. Health care coverage for you, your husband or wife and all your
children who depend on you for support. Choose one below:
• Please show current proof of Medicaid, CHIP, CHIP Perinatal,
Medicare or health insurance.
7. If you have Medicare:
• You must fill out a Medicare Asset Form (English, Spanish,
Vietnamese) and show proof of your current resources and liabilities
(all pages of bank statements, credit card bills, loans, etc.).
• You must fill out papers for CHIP, CHIP Perinatal, Medicaid, TANF
(Temporary Assistance for Needy Families), SSI (Supplemental
Security Income) or Title V benefits if you can have these programs.

6. Fill out Application
Turn in the application
Option 1: Mail to :
HCHD Financial Assistance Program PO BOX
300488
Houston, TX 77230
Option 2: Call and make an appointment to turn in:
Phone number: (713) 566-6509

7. After submitting your application:
• Turning in your required forms to an eligibility center and
they will tell you within about 14 days whether you are
eligible.
• If you or a family member need an immediate surgery or therapy,
you can speed up this process by requesting expedited
processing of your forms.
• You will get a letter that lists who in your household is
eligible for the approved plan.
• If you are approved, you need to bring an ID to your first
medical visit at a Harris Health System hospital.
• Your palm will be scanned in order to enter you into the system
• You will NOT get a physical gold card.

8. Are you under 18?
• You must first have applied to CHIP and received a
rejection letter from CHIP before they will grant you a gold
card.
to find out more about CHIP