Navigating healthcare costs can be challenging, especially when it comes to affording necessary medications. Harris Health System understands these difficulties and offers a vital Connection To Care Patient Assistance Program to help eligible patients access the medications they need at no cost. This program, often referred to as the Medication Assistance Program (MAP), is designed to connect you with pharmaceutical companies’ assistance programs, ensuring you receive your prescriptions without financial burden.
Harris Health’s dedicated pharmacy staff are experts in enrolling patients into these patient assistance programs. To start this process and establish your connection to care patient assistance program, you will need to provide some essential documents to confirm your eligibility for Harris Health financial assistance and various medication programs. This guide outlines the necessary paperwork, making the process clear and straightforward. By gathering these documents, you are taking the first step towards accessing crucial medication support through Harris Health.
To begin your application and establish your connection to care patient assistance program, please prepare copies of the following documents for yourself and, if applicable, your spouse. These documents are essential for Harris Health Financial Assistance, Drug Replacement programs, and certain federal grants.
Essential Documents for Your Patient Assistance Program Application
The following categories detail the documents required to process your application efficiently and connect you with the connection to care patient assistance program.
1. Identification Documents
Providing proper identification is the first step in establishing your eligibility. This helps Harris Health verify your identity and marital status, if applicable.
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Proof of Marriage (if applicable):
- Marriage license or IRS 1040 tax return if married.
- Declaration and Registration of Informal Marriage if you have a common law marriage.
- Other official proof of marriage can also be considered.
For those declaring a common law or informal marriage, specific forms may be required:
- If you possess the DSHS Form VS-180.1, this will serve as valid proof.
- If you do not have the DSHS Form VS-180.1, please download and print THHSC Form H1057. Complete and ensure both partners date and sign the form.
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Photo Identification (One of the following):
- State-issued driver’s license or state-issued ID card.
- Current student ID or current employee job badge.
- Valid passport or U.S. immigration documents.
- Foreign consulate ID card or agency letter.
- Current enhanced public library photo ID card or National Electoral Institute (INE) photo ID card.
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Non-Photo Identification (If you lack photo ID, provide TWO of the following):
- Birth certificate (Married women can use their maiden name birth certificate with a marriage license or child’s birth certificate showing maiden name).
- Marriage license or Declaration and Registration of Informal Marriage.
- Social Security card.
- Other federal document showing your name and Harris County address.
- Hospital or birth records, adoption papers or records.
- Current Harris County voter card or current check stub.
- Medicare or Medicaid card.
2. Proof of Address
Verification of your Harris County address is crucial to confirm your service area eligibility for the connection to care patient assistance program. Please provide one of the following documents dated within the last 60 days, showing your name or your spouse’s name:
- Utility bill or check stub.
- School record for children under 18 or mortgage coupon.
- Credit card statement or certification documents/benefit checks from Social Security Administration or Texas Workforce Commission.
- Certification documents from SNAP or SNAP Form TF0001.
- Letter from an agency or Harris Health System Agency Letter.
- Medicaid or Medicare letter or letter from a recognized social services agency.
- Business mail or statement from a licensed child care provider.
- Harris Health System Residence Verification Form (English, Spanish, Vietnamese) completed by a non-related person not living in your house.
Alternatively, you can provide one of the following documents dated within the last year:
- Lease agreement or Department of Motor Vehicles record.
- Property tax document or automobile insurance documents.
- Automobile registration or Harris County voter card.
- Printout from IRS of the most current year’s tax filing.
3. Gross Income Verification
To assess your financial eligibility for the connection to care patient assistance program, Harris Health requires proof of gross income for the past 30 days for yourself, your spouse, and any children over 18 living with you. As a mandatory step for Harris Health Eligibility, every household member over 18 must sign the application, authorizing Harris Health to verify income information with the Texas Workforce Commission (TWC).
Acceptable income verification documents include:
- Cash income, dividends, and royalties records.
- Rental property income or alimony documentation.
- Workmen’s compensation or military pay and allowances statements.
- Current check stubs or child support documents.
- Current IRS 1040/1040A tax return (all pages) if self-employed.
- Harris Health System Statement of Self Employment Income Form (English), (Spanish, Vietnamese) if no tax return is filed.
- Harris Health System Wage Verification Form (English, Spanish, Vietnamese) for cash and personal check wages.
- Social Security award letter or Retirement award letter.
- Veteran Affairs letter or check, Agency letter, or Income information on SNAP form TF0001.
- Unemployment benefit records or Harris Health System Statement of Support Form (English, Spanish, Vietnamese) if you have no income.
4. Proof of Relationship for Dependent Children
If you are including children in your application who depend on you for support, you must provide documentation proving your relationship. This ensures that the connection to care patient assistance program extends support to your family members.
Acceptable documents include:
- Birth certificate or baptismal record.
- Proof of full-time school enrollment for students aged 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.
- Death certificate for previous household members (if applicable).
- U.S. Department of Health and Human Services – Office of Refugee Resettlement-Verification of Release Form (ORR UAC/R-1) for Unaccompanied alien child.
5. Immigration Status
For yourself, your spouse, and all dependent children included in the application, you must provide documentation of immigration status. This is a standard requirement for many assistance programs to verify eligibility.
- Current or expired documents from the U.S. Citizenship and Immigration Services are required.
6. Health Care Coverage Information
Details of your current health care coverage are needed to coordinate benefits and ensure you receive the most comprehensive assistance.
- Please provide current proof of Medicaid, CHIP, CHIP Perinatal, Medicare, or private health insurance.
7. Medicare Asset Form (If Applicable)
If you are a Medicare beneficiary and eligible for the Harris Health System Financial Assistance Program, additional documentation regarding your assets is required.
- You must complete a Medicare Asset Form (English, Spanish, Vietnamese) and provide proof of your current resources and liabilities (all pages of bank statements, credit card bills, loans, etc.).
8. Program Enrollment Forms
Harris Health may require you to apply for other relevant assistance programs for which you might be eligible. This ensures you maximize available resources and support.
- You may need to fill out applications for programs such as CHIP, CHIP Perinatal, Medicaid, the Health Insurance Marketplace, TANF, SSI, Title V, or the Healthy Texas Women Program (HTWP), if you are potentially eligible for these programs.
Take the Next Step in Connecting to Care
Gathering these documents is your crucial first step in establishing a connection to care patient assistance program with Harris Health. By providing these materials, you enable Harris Health pharmacy staff to efficiently process your application and connect you with the medication assistance you need.
For further information or assistance with your application, please contact the Harris Health pharmacy or eligibility services. They are ready to help you navigate this process and ensure you gain access to affordable and essential medications through the connection to care patient assistance program.
