This form is an Assignment of Money Due. The assignor agrees to grant to the assignee all title and interest in a certain debt or money due as described in the agreement. The form also provides that it is the responsibility of the assignor to collect the debt.
Assignment Due Form For Benefits In Harris
Category:
State:
Multi-State
County:
Harris
Control #:
US-00422
Format:
Word;
Rich Text
Instant download
Description
Form popularity
FAQ
The Harris Health Financial Assistance Program (Gold Card) is a Texas public health benefit provided by the Harris Health System that provides financial assistance for medical care for Harris County residents.
Harris Health Financial Assistance Program (Gold Card) Texas I.D. or drivers license stating the person lives in Harris County. Social Security Card. Citizenship(Passport or Birth Certificate) or Green Card. Proof of income (1 months check stubs) Any bills or bank statement (within 60 days) Income tax (if necessary)
The FPL varies based on household size: one person ($19,320), two people ($26,130), three people ($32,940), four people ($39,750), or five people ($46,560). If your household income exceeds 150% FPL, you can still receive medical treatment through Harris Health System but won't qualify for discounted services.
How do I renew my Harris County Gold Card? Gold Card Renewal Application To reapply you will need to complete a Harris Health application. This application is the exact same document that you completed when you first applied for Gold Card coverage.
Anyone is eligible regardless of age, income, or immigration status. You must be a Harris County resident.
What is the Harris Health Financial Assistance Program? The Harris Health Financial Assistance Program is a program that is available to Harris County residents whose gross family income, as it relates to family size, falls at or below at or below 150% of the Federal Poverty Level.
For questions call 713-566-6509 (Monday – Friday, 8am – 4pm) to speak to the Eligibility Call Center team member for any questions regarding the Harris Health Financial Assistance Program.
More info
Agreement To Repay and Assignment Of. Future Earnings forms must be signed every time a person applies or reapplies for HR benefits. Use this form if you receive a surprise bill for health care services and want the services to be treated as in network.Not all forms are listed. In New York State, the deadline to file a no-fault claim is within 30 days of the accident. Beneficiary referral and Ticket assignment agreements between VR and EN - Pennsylvania (PDF); Beneficiary referral and Ticket assignment between VR and EN. Our office will accept an assignment of benefits from your insurance company with the provisions listed below.
