Sliding Fee Discount Program

Requested Documents

Income and household size are the only eligibility criteria for the Sliding Fee Discount Program.

A household consists of the following individuals living under one roof: the applicant, their spouse/partner, dependent children under 18 years of age, and anyone else under legal responsibility of the applicant or spouse/partner.

Remember: Help is always available. Reach out to a financial assistant at eligibility@lonestarfamily.org or 936-539-4004 for questions or assistance

  • Completed applications are accepted in person at any Lone Star Family Health Center location or via email at eligibility@lonestarfamily.org

For each household member:

1) Income from work received within last 30 days:

  • Copy of Paystubs or Pay Statements (including tips if applicable)

OR

  • If self employed, a completed "SelfEmployment Statement"

OR

  • If paid in cash, a completed "Employer Verification Form"

2) Other income received within last 30 days:

  • Most recent benefit award letter (Social Security, Disability, Retirement, Unemployment, Pension, Survivors)
  • Alimony/Child Support Receipts or Office of Attorney General report
  • Rental income documentation
  • Investment account statements

For households with zero income:

  • A completed "Statement of Financial Support"

One of the following that lists your address, dated within last 30 days:

  • Utility bill (electric, gas, telephone/ internet, cable) *no cell phone bills accepted
  • Rent receipt, printout, or copy of most recent lease agreement
  • Current Driver's License or State ID
  • Any personal or business mail or envelope (must include dated postal seal)

For each adult living in household:

  • Copy of photo ID (Driver's License, State ID, Matricula Consular, Legal Permanent Resident Card, Employment Authorization Card, Passport, or Visa)
  • Copy of Paystubs or Pay Statements (including tips if applicable)

For each minor (under 18) living in household:

  • Copy of Birth Certificate/Records with parent name that matches a listed household member (from any State/ Country)
  • Legal documentation to reflect adoption, guardianship, foster care

Applicant Information

Household Information

A household consists of the following individuals living under one roof: the applicant, their spouse/partner, dependent children under 18 years of age, and anyone else under legal responsibility of the applicant or spouse/partner.


Please fill in line (1) with your information. Fill in the remaining lines for those who live in the household.

Name (Last, First, Middle)

Relationship

Date of Birth

Age

Sex

Race1

Ethnicity2

UDS3

Annual Income:

1 Race (Please indicate race for each household member above)

A – Asian Indian

AI – American Indian, Alaska Native

B – Black

CH – Chinese

F – Filipino

G – Guamanian or Chamorro

J – Japanese

K – Korean

NH – Native Hawaiian

O – Other Asian

OPI – Other Pacific Islander

S – Samoan

U – Unreported / Unknown

V – Vietnamese

W – White

2 Ethnicity (Please indicate ethnicity for each household member above)

AH – Another Hispanic, Latino or Spanish Origin

CU - Cuban

PR – Puerto Rican

MX – Mexican, Mexican American, Chicano

NHL – Not Hispanic, Latino or Spanish Origin

U – Unreported / Unknown

3 UDS (Please indicate which, if any, of the following statuses apply to any household member above)

H – Homeless

VET – Veteran

MAW – Migrant Agricultural Worker: primary employment is in agriculture and who establish a temporary home elsewhere.

SAW – Seasonal Agricultural Worker: primary employment is in agriculture on a seasonal basis but do not establish a home elsewhere.

Please Read and Sign

Please note that we follow the Federal Poverty Guidelines established by the U.S. Government for the current year to determine your eligibility. Falsification of any information and/or documentation will disqualify you from receiving services under the Sliding Fee Discount Program. Payment is due and payable at the time of service. Re-qualification is required annually on your eligibility anniversary date to maintain participation in the program. The Sliding Fee Discount Program is not health insurance.


I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct and understand it may be confirmed through a third-party vendor. I further agree to notify Lone Star Family Health Center of any changes in this information within ten (10) days of such change.

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