Road Map for Appointments

What do I need to bring to my Eligibility Appointment or New Patient Appointment?

Please bring the following important documents:

Identification– bring one of these for each related adult and child in the household:

• • Adult: Driver’s license, ID card, passport or immigration documents
  • Child: Birth certificate or school records

Proof of income– bring at least one of the following for all income sources in the household:

• • Paycheck stubs (most recent full month)
  • Social Security documents
  • Tax returns
  • Letter of employer stating pay rate and frequency of pay
  • Statement of financial support from any other source of income

Proof of Address– bring at least one of the following:

• • Mail with your name
  • Lease agreement
  • House payment coupon
  • Voter registration
  • Utility bill

What if I don’t qualify for program-based assistance?

During your eligibility appointment, we will match your personal circumstance to all available programs and determine which is most appropriate for you. If you do not qualify, we may be able to offer other options that reduce the cost of your care.

What else should I know about these programs?

• You must provide information annually to maintain your eligibility.
• Falsifying information may result in loss of discounts, and full fees may become due.
• The use of services will not be reported to third parties.

Patient Registration Form 

Patient and Center Rights and Responsibilities

Notice of Privacy Practices and Patient Rights

Acknowledgement of Receipt

Telephone Consumer Protection Act (TCPA)

Consent to Photograph Form

Consent to Treatment Form

Patient Authorization for Greater Houston Healthconnect

Financial Responsibility and Insurance Assignment Consent

Household Eligibility Form

Statement of Support

Please call our Medical Records department at (713) 660-1880 ext. 1420 for additional information.

Authorization for Disclosure of Health Information