Download Your Gold Card Application
In this article, you will find a link to download your Harris Health Gold Card application.
Download Your Gold Card Application HERE ↓↓
Table of Contents
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:
1. Identification
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.
- 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.
- 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
- 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.
