Date: ______________________
Name: _____________________ SSN: _________________
Complete the following information for the area you want to move under the
portability option.
Name of Agency: _____________________________________________
Address: ___________________________________________________
City, State, Zip: ______________________________________________
Contact Person: _____________________________________________
I will be moving out of my current address effective: __________________
Client’s Signature: ____________________________________________
GHA Use Only
Approved: ______________ Denied: __________________
Date Portability paperwork mailed to receiving HA: ___________________
Reason: ____________________________________________________
Case Manager Signature: _______________________________________
210 Carver St. Suite 201B, Garland, TX 75040 Tel: 972-205-3393 Fax: 972-205-3388
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