Get Individual Eligibility Form - Texas Department Of State Health ...

Completing the INDIVIDUAL Eligibility Form is an essential step in accessing health services through the Texas Department of State Health Services. This guide provides clear, step-by-step instructions to help you navigate the form effectively online.

Follow the steps to fill out the INDIVIDUAL Eligibility Form.

1. Press the ‘Get Form’ button to access the INDIVIDUAL Eligibility Form and open it in your preferred online editor.
2. Begin with Part I - Applicant Information. Fill in your name, telephone number, email address, Texas residence address, city, county, state, and ZIP code. The Social Security Number is optional. Provide your date of birth, age, race, and ethnicity as required.
3. In the contact preference section, indicate how you would like to be contacted by checking the appropriate boxes for mail, phone, or email. Next, indicate whether you have comprehensive health care coverage by selecting yes or no.
4. If you answered yes about having health coverage, select all applicable benefits you receive, such as CHIP Perinatal, Medicaid for Pregnant Women, or others.
5. Proceed to Part II - Household Information. Indicate the total number of individuals in your household, including yourself and those for whom you are legally responsible.
6. In Part III - Income Information, list all sources of income for your household. Fill the table by providing the name of the person receiving the funds, the agency or employer providing the funds, and the monthly amount received.
7. Move on to Part IV - Applicant Agreement. Read the Rights and Responsibilities statements carefully and confirm your understanding by checking yes or no. Sign and date the application, and if someone assisted you, they should also sign and state their relationship to you.
8. Finally, in Part V - Provider Eligibility Certification, this section should be completed by the provider. They will need to verify residency, total monthly income, eligibility for programs, and sign and date the certification.
9. Once all parts are completed, you may save changes, download the form, print it, or share it as necessary to submit your application.

Complete the INDIVIDUAL Eligibility Form online today to ensure access to necessary health services.