Chambers County, TX · Chambers County
County Indigent Health Care Program Application for Health Care Assistance
This application lets Chambers County residents request County Indigent Health Care Program assistance and provide household, income, resource, and health coverage information.
At a glance
- Issued by
- City of Chambers County · Chambers County, Chambers County, Texas
- Notarization
- Not required: file this form without a notary.
- Official source
- chamberscountytx.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this application to request help paying for needed health care through the County Indigent Health Care Program. It asks about household members, county residence, living arrangements, expenses, benefits, health coverage, resources, property, work, and income. The packet also includes program instructions, a privacy notice acknowledgment, a support and contributions statement, and a list of documents that may be needed to complete a case.
Who needs it
Chambers County residents seeking County Indigent Health Care Program assistance should complete the application and answer as many questions as they can.
How to submit it
Turn in or mail back the application to the County of Chambers Indigent Health Care Office, P.O. Box 489, Anahuac, TX 77514.
About notarization
This application is signed without a notary; the applicant and other listed signers sign and date it, and a person providing support signs the attached statement.
How to submit this form
- 1
Download the Application
Download the County Indigent Health Care Program application PDF.
- 2
Complete the Application
Enter your household, residence, expense, benefit, coverage, resource, property, work, and income information; answer as many questions as you can.
- 3
Gather Supporting Documents
Review the listed examples of proof, including identification, residency and income documents, bank statements, and vehicle registration or title.
- 4
Sign and Submit
Sign and date the application, then turn it in or mail it to the County of Chambers Indigent Health Care Office, P.O. Box 489, Anahuac, TX 77514.
Frequently asked questions
- Who can use the Chambers County health care assistance application?
- Residents requesting help through the County Indigent Health Care Program can use this application to provide household, income, resource, residence, and health coverage details.
- Do I need a notary for the health care assistance application?
- No. The application is signed without a notary. The applicant and other listed signers sign and date it; a person providing support signs the attached support statement.
- How do I submit the Chambers County application?
- Turn in or mail the application to the County of Chambers Indigent Health Care Office, P.O. Box 489, Anahuac, TX 77514.
- What information should I include?
- The form asks about household members, residence, expenses, benefits, health coverage, money, vehicles, property, work, and income. It also lists examples of proof you may be asked to provide.