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DSHS Family & Community Health Services Division
INDIVIDUAL Eligibility Form

Location Name : 8150 Southwest Freeway, Houston TX 77074

Make sure you've entered your information same as on your passport

PART I - APPLICANT INFORMATION

Race :

Patient Ethnicity :

Please contact me by: (check all that apply) :

Do you have comprehensive health care coverage (Medicaid, Medicare, CHIP, health insurance, VA, TRICARE, etc.)?

Which benefits or health care coverage do you receive? (check all that apply)

PART II – HOUSEHOLD INFORMATION

Fill in the box with the number of people in your household. This number will include you and anyone who lives with you for whom you are legally responsible. Minors should include parent(s)/legal guardian(s).

PART III - INCOME INFORMATION

List all of your household’s income below. Include the following: government checks; money from work; money you collect from charging room and board; cash gifts, loans, or contributions from parents, relatives, friends, and others; sponsor’s income; school grants or loans; child support; and unemployment benefits.

Name of person receiving money	Name of agency, person, or employer provides the money	Amount received per month

PART IV - APPLICANT AGREEMENT

I have read the Rights and Responsibilities statements in the instructions section of this form.

The information that I have provided, including my answers to all questions, is true and correct to the best of my knowledge and belief. I agree to give eligibility staff any information necessary to prove statements about my eligibility. I understand that giving false information could result in disqualification and repayment. I authorize release of all information, including income and medical information, by and to the Texas Department of State Health Services (DSHS) and Provider in order to determine eligibility, to bill, or to render services to me.

Signature – Applicant:

Date:

Signature – Person who helped complete this application

Relationship to Applicant

Date

PART V – PROVIDER ELIGIBILITY CERTIFICATION (to be completed by provider)

Texas resident

Total monthly household income

Household FPL

Proof of income

Verification of adjunctive eligibility

Presumptively eligible

Presumptively eligible

Full eligibility met

Is the client eligible for the following program(s)?

BCCS

Co-payment amount (if applicable)

DSHS FP

Co-payment amount (if applicable)

EPHC

Co-payment amount (if applicable)

PHC

Co-payment amount (if applicable)

Title V/MCH

Co-payment amount (if applicable)

Name of Agency

Signature – Agency / Staff Member

Date

DSHS Family & Community Health Services Division
INDIVIDUAL Eligibility Form

Check all the boxes that apply.
Check yes or no.

CHIP (Children’s Health Insurance Program) Perinatal

Medicaid for Pregnant Women

SNAP (Supplemental Nutrition Assistance Program)

TWHP (Texas Women’s Health Program)

WIC (Special Supplemental Nutrition Program for Women Infants and Children)

None

If you selected one of these benefits or health care coverage programs and you are able to provide proof of current enrollment, you may be adjunctively (automatically) eligible for a DSHS Family & Community Health Services Division program and able to skip Part II and III on this application, if your agency does not collect a co-pay. (Exception -- Adjunctive eligibility does not apply to applicants seeking Title V services.)

PART II – HOUSEHOLD INFORMATION

Fill in the box with the number of people in your household. This number will include you and anyone who lives with you for whom you are legally responsible.

How to determine your household:

If you are married (including common-law marriage), include yourself, your spouse, and any mutual or non-mutual children (including unborn children).
If you are not married, include yourself and your children, if any (including unborn children).
If you are not married and you live with a partner with whom you have mutual children, count yourself, your partner, your children, and any mutual children (including unborn children).

Applicants 18 years and older are adults. Do not include any children age 18 and older, or other adults living in the house, as part of the household. Minors should include parent(s)/legal guardian(s) living in the house.

PART III - INCOME INFORMATION

List all of your household’s income in the table. Include the following: government checks; money from work; money you collect from charging room and board; cash gifts, loans, or contributions from parents, relatives, friends, and others; sponsor’s income; school grants or loans; child support; and unemployment benefits.

Fill in the table with the following information:

1st column: 2nd column: 3rd column:
The name of the person receiving the money.
The name of the agency, person, or employer who provides the money. The amount of money received per month.

PART IV - APPLICANT AGREEMENT

Rights and Responsibilities:

If the applicant omits information, fails or refuses to give information, or gives false or misleading information about these matters, he/she may be required to reimburse the State for the services rendered if the applicant is found to be ineligible for services. The applicant will report changes in his/her household/family situation that affect eligibility during the certification period (changes in income, household/family members, and residency). (MBCC clients are not required to report changes in income, household, and residency)
The applicant understands that, to maintain program eligibility, he/she will be required to reapply for assistance at least every twelve months (not applicable to MBCC).

The applicant understands he/she has the right to file a complaint regarding the handling of his/her application or any action taken by the program with the HHSC Civil Rights Office at 1-888-388-6332.

The applicant understands that criteria for participation in the program are the same for everyone regardless of sex, age, disability, race, or national origin.

With few exceptions, the applicant has the right to request and be informed about information that the State of Texas collects about him/her. The applicant is entitled to receive and review the information upon request. The applicant also has the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 522.023 and 559.004)

Read the Rights and Responsibilities above. Check yes or no.
Sign and date on the lines. If a person helped you complete the application, he/she should sign, state the relationship to you, and date on the lines.

PART V – PROVIDER ELIGIBILITY CERTIFICATION (to be completed by provider)

(1) Check the appropriate box (yes or no) for Texas resident. (2) Total the amount received per month to fill in the Total monthly household income box. (3) Calculate the client’s household FPL using the applicable DSHS program policy (include applicable deductions) and fill in the Household FPL box. Check the appropriate box (yes, no, waived, or n/a) for (4) Proof of income and (5) Verification of adjunctive eligibility.
If client is presumptively eligible, fill in the light gray box. (6a) Check the appropriate box (yes, no, or n/a) for Presumptively eligible.
Once the client completes the requirements for full eligibility, (6b) check Yes for Full eligibility met and fill in the (6c) Full eligibility met date box.
(7) Check the appropriate box (yes, no, or n/a) for each program regarding the client’s eligibility. If yes, fill in the client’s co-payment amount for the program based on their household and income information.
Use the space provided in Notes to document other appropriate information concerning eligibility and screening. Fill in the Eligibility effective date box in the top right corner of Part V. Fill in the Name of Agency, sign, and date.