Fill - Free fillable WEBB COUNTY INDIGENT HEALTHCARE SERVICES In order to (Webb County) PDF form

WEBB COUNTY INDIGENT HEALTHCARE SERVICES

1620 Santa Ursula Ave.

(956) 523-4747; FAX: (956) 523-4748

E-mail: indigenthealth@webbcountytx.gov

REQUIRED DOCUMENTS TO PROCESS PROGRAM APPLICATION

In order to process your application, you must bring in the following documents needed, if

applicable to you, in order to determine program eligibility.

 Texas ID  Texas DL  Provide Last Four Paystubs

 US Passport  MX Passport  Self-Employed

(Provide income tax forms

 Resident Card  Consulate Card

or business records)

*If applicant does not have an ID, list why:  Income Tax Return

(including all forms)

________________________________  Child Support Benefits

________________________________  Any Social Security Benefits

 Veteran’s Assistance

 Retirement Benefits

 Worker’s Compensation

 Birth Certificate  Unemployment Benefits

 Social Security Card

(if applicable)  Proof of Loans, Gifts or Contributions

*If applicant does not have any, list why: *If there is no income, list how bills are paid:

________________________________ __________________________________

 Current Rent Receipt or Contract  If you are able to work, provide proof of

 Mortgage Payment Registration with Texas Workforce

 Property Deed or Tax Statement Commission.

 Current Utility Bills

(provide at least 2):

 Light, Water or Gas

 Bank Account(s) Statement

(checking,

savings or other bank accounts)

 Medicare  Title of Vehicles under applicant’s name

 Medicaid  Real Estate (current tax statement)

 SNAP/ Food Stamps  If Divorced, must present Divorce Decree

 TANF Assistance

 Proof of any Job-Related Life Insurance, Please provide a phone number to contact

Life, Burial or other Health Insurance applicant for a phone interview:

 Students: Proof of Grants, Loans &

Tuition, Scholarships, School Records ______________________________

DURING THE INTERVIEW, THE CASEWORKER MAY REQUEST ADDITIONAL

DOCUMENTS NEEDED TO DETERMINE PROGRAM ELIGIBILITY.

1) Valid Photo Identification Card for Applicant

2) Citizenship Documentation

3) Proof of Residence: Home & Utility Bills

proof of residence under home owner’s name)

(if applicant lives in another person’s home, provide

4) State Benefits Received: Must provide

Award/ Denial Letter or appointment Notice)

6) Proof of all Household Income (if applicable):

7) Unemployment:

8) Resources:

5) Other Benefits:

9) Contact Information:

Webb County Indigent Health Care Services Department

1620 Santa Ursula Ave.

Laredo, TX 78040

(956) 523-4747 • Fax (956) 523-4748

Authorization Form

I, __________________________, give authorization to the person listed below

to represent me at any moment that I am not physically able to attend any

appointments. I also authorize this person to answer any questions regarding my

welfare as well as to be given any information regarding my Webb County

Indigent Health Care case.

*Copy of Identification Required*

Applicant’s Signature: _______________________________

Date: ____________________

Authorized Person:

Relation to Applicant:

Phone Number:

Address:

D.O.B

(Applicant’s Name)

click to sign

signature

click to edit

WEBB COUNTY INDIGENT HEALTHCARE SERVICES PROGRAM

In order to better assist each applicant, this questionnaire should be filled out

completely.

Applicant’s Name: Case #

A phone interview will be conducted by a Caseworker to determine program eligibility. The length

of the interview can vary between 5-30 minutes.

What language do you prefer to have the interview conducted in?  English  Spanish

Medical Need:

1) What type of medical assistance do you need? (check all that apply)

 Hospital bills from:  LMC  Doctors Hospital  Other: ________________________________

 Medical Specialist: ________________________________________________________________

 Primary Care: ____________________________________________________________________

 Exams: _________________________________________________________________________

 Medications: _____________________________________________________________________

 Other: __________________________________________________________________________

2) Are you currently registered at any health care clinic:

 Gateway  Border Region  Mercy Ministries  City of Laredo  Other:__________________________

3) Are you currently taking medications?  Yes  No

4) Do you have any of the following health benefits/insurance:

Health Insurance:  No  Yes:___________________________________

Medicaid:

 No  Yes

Medicare:

 No  Yes

5) If applicable, does your spouse or any minor legal dependent have any of the

following health benefits/insurance:

Health Insurance:  No  Yes:_______________________________

Medicaid:

 No  Yes

Medicare:

 No  Yes

CITIZENSHIP STATUS: (Select current status)

 United States Citizen-By Birth

 United States Citizen-By Naturalization on Date: ________________

Date entered into U.S.:________________ Country of Origin: ______________________________

 United States Resident Alien: Immigration Date: ________ Sponsored By: _______________

Date entered into U.S.:_______________ Country of Origin: _______________________________

 United States Legal Resident through a federal immigration program:

 DACA (Deferred Action for Childhood Arrivals)

 VOWA (Violence Against Women Act)

 Other: __________________________________________________

*Date entered into US: _________________ Country of Origin: _____________________________

 Undocumented: Date entered into U.S.________________ Country of Origin: _______________

Are you in the process of being immigrated:

 No  Yes, Sponsor:__________________________

Current Marital Status:

(Advise Caseworker if more than one status applies)

 Single (never married)

 Legally Married since: __________ Name of Spouse: _____________________________________

Did you, or spouse, file an income tax this year?  Yes  No. Last file date was on: _______________

 Common-Law since: __________ Name of Spouse: _______________________________________

Are you free to marry?

 Yes  No, still legally married to another person.

Do you currently live with your spouse?

 Yes  No

Did you, or spouse, file an income tax this year?  Yes  No. Last file date was on: _______________

 Separated since: __________ Name of Spouse: __________________________________________

Current address of Spouse: __________________________________________________________

Did you, or spouse, file an income tax this year?  Yes  No. Last file date was on: ______________

 Divorced since: __________ Name of Ex-Spouse: _________________________________________

Current address of Ex-Spouse: ______________________________________________________

 Widow since: _____________ Name of spouse: ______________________________________

Employment History:

1) Are you or your spouse currently employed? (Check all that apply)

 Never worked

 No. The last time worked was on ________________ at __________________________________

 Yes, I am Employed at _____________________________________________________________

 Yes, My Spouse is Employed at ______________________________________________________

 Yes, I am Self-employed/Own Business: _______________________________________________

Is your business registered in the state of Texas?  Yes  No

 Yes, My Spouse is Self-employed/Own Business: ________________________________________

Is their business registered in the state of Texas?  Yes  No

2) Are you currently applying for or receiving any of the following benefits?

(Check all that apply):

 Unemployment  Workers’ Compensation  Crime Victims Compensation  Retirement

Social Security Benefits:

1) Do you receive any Social Security/SSI (Supplemental Security Income) benefits?

No Yes

2) Are you in the process of applying for Social Security/SSI benefits?

 No  Yes, Date of application was turned in: ___________________________________

3) What level is your Social Security application on?

 New Application  Appeal  Reconsideration  Hearing Request

Resources:

1) Do you have any bank accounts:  No  Yes, Bank Name:____________________________

What type of Bank account:  Checking  Savings  Other:__________________________

2) Do you own any properties other than where you currently live?:  No

 Yes, Address: ___________________________________________________________________

Residency:

What are your current living arrangements? (Check all that apply)

 Own/Paying for home  Rent a House/Apartment  No permanent home

 Live in a house provided by someone else. Name: ________________________________

 I help pay for household bills.  I do not pay any household bills.

Financial Assistance/Support:

1) Are you able to cover your monthly household expenses with the money you have or

receive?  Yes  No

2) Do you receive any financial assistance/support from someone or an assistance program

to pay for rent, utility bills, gas, personal items, etc.?  No

 Yes, by _______________________________________ Amount: $____________________

3) How do you receive the financial assistance mentioned above, if any?

 Cash  Bank Deposit  Program Voucher  Rent or bills are paid directly to the companies.

*Person(s)/Programs providing financial assistance will need to provide proof of support and sign a

Financial Support Form.

Have you or anyone in your household received this month, within the last 3 months or expect

to receive money from any of the following (please respond to each item):

Check one:

Monthly Amount:

Loans

 No

 Yes

Cash Gifts or Contributions

 No

 Yes

Social Security or Supplemental Security Income (SSI)

 No

 Yes

Veteran’s Benefits or Pension

 No

 Yes

Baby Sitting or Cleaning Houses

 No

 Yes

Child Support

 No

 Yes

Alimony

 No

 Yes

Dividends from Stocks/bonds/bank accounts

 No

 Yes

Interest or Royalties

 No

 Yes

Money or Royalties from Oil, Gas or mineral leases

 No

 Yes

Money from Rent of Houses, Apartments, property, etc.

 No

 Yes

Money from roommates or boarders

 No

 Yes

Payments from private insurance

 No

 Yes

Flea Market, Garage/yard sales, Arts and Crafts Sales

 No

 Yes

Food plate sales

 No

 Yes

Fundraisers: Go Fund Me Account, Facebook, etc.

 No

 Yes

Home Sales: Avon, Mary Kay, Tupperware, Etc.

 No

 Yes

Other Miscellaneous work/sales

 No

 Yes

I certify that the information provided in this questionnaire is true and correct.

__________________________________ ___________________

Applicant Signature Date

If you are filling this questionnaire out for an applicant, you certify that the information provided in this

questionnaire is true and correct and to the best of your knowledge.

_____________________________ _____________ _______________________

Signature Date Relation to Applicant

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

WEBB COUNTY INDIGENT HEALTHCARE SERVICES In order to (Webb County)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank WEBB COUNTY INDIGENT HEALTHCARE SERVICES In order to (Webb County) Form

Related forms

Fillable WEBB COUNTY INDIGENT HEALTHCARE SERVICES In order to (Webb County)

Fill Online, Printable, Fillable, Blank WEBB COUNTY INDIGENT HEALTHCARE SERVICES In order to (Webb County) Form

Related forms

First 20 documents completely FREE!