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ww.myaccesshealth.org
How to Apply for Discounted Services
Primary Healthcare
You may make an appointment at the AccessHealth Richmond, Stafford, Missouri City or Brookshire clinics to apply for
discounted services. To apply as a patient, our state funding requires you to bring in:
1. Proof of Identification: (1 for each family member):
Birth Certificate, or
Baptismal Certificate, or
School Records, or
Valid Texas Driver’s License, or
USCIS Documentation, or
Passport.
2. Proof of Address:
Current water, electric or gas bill statement from utility department, or
Lease/Rent Receipt, or
Medicaid Letter, or
Motor Vehicle Registration, or
Property Tax Receipt.
3. Proof of Gross Income: (needed for every family member who is employed)
2 MOST CURRENT paystubs no more than 60 days old, or
If you are paid in cash, you will need an Employment Verification Form (available at any of our
locations), or
If you are not working, you will need a Supporter Statement with a copy of ID of the person who helps
you (available at any of our locations), or
Current Tax return.
4. If anyone in your household receives any of following , please bring a current copy:
VA Benefits, Social Security Income, Worker’s Compensation, Unemployment Benefits, Child Support, or Self-
Employment Records.
5. If anyone in your household receives Medicare, CHIP or Medicaid, Please bring your ID card or letter.
**If you are applying for the Healthy Texas Women’s Program, please bring in your birth certificate along
with another form or identification**
To schedule an appointment for registration, please call 281-342-4530.
Rev. 8/2018
(Office Use Only)
Acct No:
www
.myaccesshealth.org
400 Austin St Richmond, Texas 77469
Household Composition Form
HEAD O
F HOUSEHOLD
Full Name: ___________________________________________ Date of Birth: ______________
(Office Use Only)
Telephone Number: _______________________________ SSN: __________________________
Acct No:
Address: ________________________________________ City: _________________________ State: ____________
Zip Code: _________________________ County: ____________________ E-Mail: ____________________________
Sex: (circle) F / M US Citizen: (circle) Yes / No Race:___________________
SPOUSE
Full Name: ___________________________________________ Date of Birth: _______________
Telepho
ne Number: ________________________________ SSN: _________________________
Sex
: (circle) F / M US Citizen: (circle) Yes / No Race: _____________________
E-Mail: __________________________________________________________________________________________
Fill in the other lines for everyone who lives with you for whom you are legally responsible.
Name (Last, First, Middle)
SSN
(optional)
Date of
Birth
Sex
Race
US
Citizen
Relationship
Use Only)
Acct #
1
F / M
Yes / No
2
F / M
Yes / No
3
F / M
Yes / No
4
F / M
Yes / No
5
F / M
Yes / No
6
F / M
Yes / No
7
F / M
Yes / No
8
F / M
Yes / No
9
F / M
Yes / No
List all of you household’s income below. Include the following: government checks; money from
work; money you collect from charging room and board; gifted money; child support; or
unemployment income.
Name of person receiving money
Agency, person, employer who,
provides the money
Amount received per month
Do you or any of your family members have medical health insurance? Yes / No : ______________________________
Rev. 8/2018
Tel: 281.261.0182
Fax: 281.969.1838
Visit us at:
www.myaccesshealth.org
10435 Greenbough Dr. Suite 300
Stafford, Texas 77477
Dental Service Agreement
Services Provided:
AccessHealth provides dental services for registered patients at the Stafford Dental Clinic. Services will be
limited to exams, cleanings, simple fillings and simple extractions. Patients who require a procedure that cannot be performed at
the Stafford Dental Clinic will be referred to an outside, non-contracted specialist.
_____
__ Initials
Responsibilities:
It is very important that you keep the appointment you have made. You must call the Dental Clinic 24 hours in
advance if you are unable to keep your appointment. Calling in advance provides us sufficient time to give the appointment to the
next person who is waiting for an appointment.
If
you miss three (3) dental appointments without calling to cancel, you will not be eligible to schedule an appointment for six (6)
months from the date of your last missed appointment. You will have the option of seeing a dental provider on a walk-in basis
during this time, depending on provider availability.
____
___ Initials
La
te Arrivals:
You are expected to arrive on time to your appointment (or earlier if possible). If you arrive late to your appointment
you will lose your reserved spot and will be placed on a standby list, which is subject to availability on the providers’ schedule. You
may also reschedule your appointment for another day. Please note, if you are unable to be seen on the same day, the appointment
will be considered a No-Show and will count towards the No-Show policy.
____
___ Initials
Parents / Guardians: Help us maintain happy, healthy smiles for you and your children.
Pa
tients under the age of 18 years have to be accompanied by a parent/guardian at all times. This policy WILL
be enforced by the
Dental Department for legal and safety reasons. If you as the parent/guardian leaves the building for any reason, your child will
not be rendered the dental services that he or she needs for that day.
_____
__ Initials
I certify that I have read and understand the above agreement
Pr
int Name DOB: _________________________________
Pa
tient/Parent/Guardian Signature Date: _________________________________
Stafford Center Hours of Operation
Monday through Friday: 7am 7pm
Every Saturday: 8am 12pm
DSHS 14-252(X) (REV. 05/2015)
Employment Verification
LOCAL OFFICE
ACCESSHEALTH
TELEPHONE NUMBER
281-342-4530
FAX NUMBER
Please use blue or black ink and print or type.
PATIENT NUMBER
DATE
Section 1: To be filled out by the client/employee.
I authorize my employer to release information to the Department of Social and Health Services.
EMPLOYEE’S SIGNATURE
SOCIAL SECURITY NUMBER (OPTIONAL)
DATE
Section 2: To be filled out by the employer.
EMPLOYEE’S NAME
EMPLOYER’S NAME
EMPLOYEE’S JOB TITLE
EMPLOYER’S ADDRESS
Is this a new job? No Yes
DATE EMPLOYEE STARTED WORK
DATE FIRST CHECK WAS RECEIVED
AVERAGE HOURS PER WEEK
RATE OF PAY OR SALARY (HOURLY,
DAILY OR PIECE RATE)
Has job ended? No Yes
If yes, when: why:
Pay frequency: Daily Weekly Every two weeks Two times a month Monthly
Is this job Work Study?
Yes No
IF YES, PROVIDE VERIFICATION OF TOTAL FINANCIAL
AID AWARD
WHEN WILL YOUR POSITION END?
Actual gross income (or attach payroll printout) for last three months:
MONTH:
$
MONTH:
$
MONTH:
$
Actual gross income for current month and anticipated gross income for next two months:
CURRENT MONTH:
$
MONTH:
$
MONTH:
$
Tips No Yes; if yes, how often and how much?
Commissions No Yes; if yes, how often and how much?
Bonuses No Yes; if yes, how often and how much?
Overtime No Yes; if yes, how often and how much?
Work schedule (include exact times when possible):
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Is Health Insurance available? Yes No
If yes, is employee enrolled in the health plan? Yes No
When does the coverage begin?
What is the employee’s portion of premiums?
EMPLOYER/REPRESENTATIVE’S SIGNATURE
DATE
EMPLOYER/REPRESENTATIVE’S PRINTED NAME AND TITLE
PHONE NUMBER
X
X
X
X
X
Form 149
Page 1 of 2
March 2017
STATEMENT OF SELF-EMPLOYMENT INCOME
DECLARACIÓN DE INGRESOS DEL NEGOCIO PROPIO
See Instructions on Page 2./Vea las Instrucciones en la página 2.
Case
Record Name Case Record Number
1. Name of Person Having Self-Employment Income/Nombre de la persona que tiene ingresos de negocio propio.
2. Give the number of months covered by this income statement.
Dé el número de meses que cubre esta declaración de ingresos. .............................................................................
3. Describe what you did to earn this money./Describa lo que hizo para ganarse este dinero.
4. List your business expenses and income. IMPORTANTE: Attach receipts, invoices, or other verifying papers.
Anote los gastos y ingresos de su negocio. IMPORTANTE: Adjunte recibos, facturas, u otros comprobantes.
Date
Fecha
EXPENSES
GASTOS
Amount
Cantidad
Date
Fecha
INCOME
INGRESOS
Amount
Cantidad
$ $
SUBTOTAL
$
$
Total Expenses
Total de Gastos
Enter expenses here and subtract.
Anote el total de gastos y reste.
NET SELF-EMPLOYMENT INCOME
INGRESOS NETOS DEL NEGOCIO PROPIO
$
The above information is true, correct, and complete to the best of my knowledge. I understand that giving
false information to the county could result in my being disqualified for fraud./Según mi leal saber y entender,
toda esta información es cierta, correcta y completa. Comprendo que si doy información falsa al condado puedo ser
descalificado por fraude.
Signature of anyone helping you to prepare this form / Date
Firma de la persona que le ayudó a llenar la forma / Fecha
Signature / Firma Date / Fecha
X
X
1
Form 149, Statement of Self-Employment Income
Page 2 of 2
March 2017
If you or any member of your household has any kind of self-
employment income, fill out this form and attach it to your
application. You may attach a copy of the latest income tax forms
in place of this form. If your accounting system is not the same as
this form, you may substitute a copy of your accounting
statement. You must answer all questions and sign and date at
the bottom. Use additional sheets of paper if you need to.
Sign and date each sheet. Remember, this is your sworn
statement. You will need to bring with you to the interview: bills,
receipts, checks or stubs, and any other business records you
have. Your worker will need to see them. Your records will be
returned to you.
Self-employment Income. This is any money you earn working
for yourself. It is not money you earn working for someone else. If
you are in doubt, ask your caseworker.
Questions 1, 2, and 3. These questions are self-explanatory.
Question 4. List your business income and expenses. In the
boxes on the left side of the form, list your business expenses
(see the information below). Write in the dates you paid the
expenses and the amount of each expense. Add the amounts,
and enter your total in the box "total self-employment expenses."
In the boxes on the right side of the form, list your income (see
the information below). List the dates you received the income,
your sources of income, and the amounts. Add the amounts, and
enter your total in the box "total self-employment income."
Subtract your expenses from your total self-employment income,
and enter your "net self-employment income."
Expenses
are your costs of doing business. Examples of
expenses are supplies, repairs, rent, utilities, seed, feed, business
insurance, licenses, fees, payments on principal of loans for
income-producing property, capital asset purchases (such as real
property, equipment, machinery, and other durable goods and
capital asset improvements), your social security contribution for
people who worked for you, and labor (not salaries you pay
yourself). If you claim labor costs, list each person and the
amount you paid them. If you have any other kinds of business
expenses, be sure to list them and the date they were paid.
You may not claim:
Rent, mortgage, taxes, or utilities on your business if it
operates out of your home (unless these costs are separate
from the costs of your home);
Cost of goods you buy for the business but use yourself;
Net business loss from a prior period and
Depreciation.
If you are in doubt, bring proof of the expense and ask your
worker.
Income
includes money from sales, cash receipts, crops,
commissions, leases, fees, or whatever you do or sell for money.
If you have any other kind of income from your business, be sure
to list it. Be sure to list the dates income was received.
Who must sign. The form must be signed by the applicant,
spouse, or authorized representative. Anyone may help you
complete the form, but that person must also sign and date the
form. Ask your worker if anyone else needs to sign the form.
Si usted u otra persona de su casa tiene algún tipo de ingresos de negocio
propio, llene esta forma y adjúntela a su solicitud. En lugar de esta forma,
puede adjuntar una copia de la declaración de impuestos sobre ingresos
más reciente. Si el sistema de contabilidad que usa no es igual al de esta
forma, puede substituir la forma con una copia de su registro de
contabilidad. Tiene que contestar todas las preguntas y firmar y fechar la
forma al final. Use hojas adicionales si las necesita. Firme y feche cada
hoja. Recuerde que ésta es una declaración jurada. Tiene que llevar a la
entrevista: cuentas, recibos, cheques o talones de cheques y cualquier otra
documentación que tenga del negocio. El trabajador tendrá que verlos.
Estos documentos le serán devueltos.
Ingresos del Negocio Propio. Este término se refiere al dinero que gana
cuando trabaja por su propia cuenta. No es el dinero que recibe cuando
trabaja para otra persona. Si tiene alguna duda, consulte con su
trabajador de casos.
Preguntas 1, 2, y 3. Estas preguntas no necesitan más explicación.
Pregunta 4. Apunte los ingresos y gastos de su negocio. En las cajas del
lado izquierdo de la forma, enumere los gastos de su negocio (vea la
información abajo). Ponga la fecha en que pagó los gastos y la cantidad
de cada gasto. Sume las cantidades y ponga el total en la caja que dice
"total de gastos del negocio propio". En las cajas a la derecha de la
forma, enumere los ingresos (vea la información abajo). Ponga la fecha
en que recibió cada ingreso, la fuente del ingreso y la cantidad. Sume las
cantidades y ponga el total en la caja que dice "total de ingresos del
negocio propio". Reste los gastos del total de ingresos del negocio propio
y anote sus "ingresos netos del negocio propio".
Los gastos
son los costos de un negocio. Algunos ejemplos de posibles
gastos son: provisiones, reparaciones, renta, servicios públicos, semilla,
forraje, seguro del negocio, licencias, cuotas, pagos del capital de
préstamos para propiedades que generan ingresos, compras de bienes de
capital (como bienes raíces, equipo, maquinaria y otros bienes duraderos y
mejoras de bienes de capital), su aportación al seguro social de las
personas que trabajan para usted y sueldos (pero no los que se paga a
mismo). Si declara el costo de sueldos, ponga el nombre de cada persona
y la cantidad que le pagó a cada quien. Si tiene cualquier otro tipo de
gastos del negocio, asegúrese de anotarlos y poner la fecha en que los
pagó.
No puede declarar:
El pago de la renta, la hipoteca, los impuestos o los servicios públicos
del negocio si lo opera de su casa (a no ser que estos costos son aparte
de los costos de la casa);
El costo de artículos que compra para el negocio pero que usa
personalmente;
La pérdida neta del negocio de un periodo anterior; and
La depreciación.
Si tiene alguna duda, lleve comprobantes del gasto y consulte con el
trabajador.
Los ingresos
son, entre otros, el dinero de ventas, el ingreso de caja, las
cosechas, las comisiones, las rentas, las cuotas o cualquier cosa que hace
o que vende por dinero. Si usted tiene cualquier otro tipo de ingresos del
negocio, asegúrese de anotarlo. No olvide poner las fechas en que recibió
el ingreso.
Quién debe firmar. El solicitante, su cónyuge o su representante autorizado
para firmar la forma. Cualquier persona puede ayudarle a llenar la forma,
pero esa persona también tiene que firmar y poner le fecha en la forma.
Consulte con el trabajador para saber si alguien más tiene que firmar.
With a few exceptions, you have the right to request and be informed about the information that the county obtains about you. You are entitled to rec
eive and
review the information upon request. You also have the right to ask the county to correct information that is determined to be incorrect (Government Code,
Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact your local county office. /
Con algunas
excepciones, usted tiene el derecho de saber qué información obtiene sobre usted el condado de pedir dicha información. Si desea recibir y estudiar la información, tiene el
derecho
de solicitarla. También tiene el derecho de pedir que el condad corrija cualquier información incorrecta (Código Gubernamental, Secciones 552.021, 552.023,
559.004). Para enterarse sobre la información y el derecho de pedir que la corrijan, favor de ponerse en contacto con la oficina local del condado.
SUPPORTER STATEMENT
If an applicant has no income or is unable to provide any documentation showing how they manage,
this form can be used as documentation. This form must be completed and signed by the person
providing support; it should not be filled out by the person applying for the program. Please bring a
copy of the ID of the person who is completing this form.
I, , certify that I currently support
(printed name of supporter)
, who resides at the following
(printed name of person you support)
address: .
(person you support’s street address, city, state, & zip code)
I have supported him/her since . My relationship to the applicant
(Date)
is .
(examples: parent, spouse, roommate, friend, sister, etc.)
The type of support I provide is (check all that apply):
Room Food/Clothing Rent/Mortgage Utility Bills
Cash Assistance in the amount of $ per month
Other:
A
dditional explanation (if necessary):
I can be reached at the following number(s) to verify this information:
By signing this form, I affirm that the above information is an accurate statement of assistance being provided to
the applicant. I understand that if I deliberately omit or give false information the applicant may be removed
from the program and/or criminally prosecuted.
Signature of Supporter (please print and sign)
Date
Please note: If there are special circumstances surrounding your household situation that would need to be explained or
verified by a social worker, case manager, or public health nurse, please have them provide a detailed support statement
on your behalf and attach it to your application when applying for assistance.
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