Self-Declare Pregnancy Form in Medi-Cal: A Guide

The Harris Health Financial Assistance Program offers a self-declare pregnancy form for patients who are eligible to apply for financial assistance. If you have recently given birth or are expecting, you may be able to receive financial support through this program.

To begin the application process, you must first determine your eligibility by reviewing the categories below:

* Patients discharged from Johnson hospitals within the past 30 days and need a follow-up appointment

* Patients discharged from Ben Taub or Lyndon B. Johnson Health Center

If you fall into one of these categories, you can apply for financial assistance at one of the health centers listed in the drop-off section.

To expedite your application, you can use the fast-track eligibility process. This will allow you to receive a preliminary determination of your eligibility and begin receiving benefits more quickly.

The self-declare pregnancy form is available online, and you can complete it using one of the following web browsers: Google Chrome, Microsoft Edge, or Safari. You will need to provide proof documents, including any relevant medical records and identification.

If you have a Harris Health System medical record number, be sure to have it available when completing your application. However, this is not required to apply for financial assistance.

Once you have completed the online application, you can upload your proof documents and submit your application. The online application process is secure and electronic-only, so you will need to use the link provided to complete your application.

By following these steps and providing the necessary documentation, you can successfully apply for financial assistance through the Harris Health Financial Assistance Program's self-declare pregnancy form in Medi-Cal.

Self declare pregnancy form in medi cal