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Step 2

STEP 2

Gather your required documents

To enroll in the JPS assistance programs, you will be required to provide several documents. You can submit these items electronically* if you apply online, or bring them when you come in for an appointment. If you wish to expedite your eligibility determination, you may submit your supporting documents by postal mail, fax, or email.
JPS Enrollment & Eligibility Center
1325 S. Main Street
Fort Worth, Texas 76104

*To submit electronically, you will need access to a fax machine or scanner.
Fax (817) 927-3834
Email eligibility@jpshealth.org with scans of the required documents.

Click here for a printable version of this list.

Click here for this list in Spanish.

Click here for this list in Vietnamese.


Documents Required:

SmallCheckMark Proof of Patient Identification (one item)

  • Driver's license or DPS ID card
  • Birth Certificate (children under 18)
  • Employee Identification card (with picture)
  • School Identification card (with picture)
  • Immigration documentation for all applicable household members: Resident alien cards (front and back), Visas and or Passports
     
 

SmallCheckMark Social Security Number for all applicable household members.
  

SmallCheckMark Most recent checking and savings account statements
 

SmallCheckMark Entire 1040 Tax Return Form with: Schedule C, Partnership tax form 1065, Schedule K-1, Schedule F, W2 etc.  

SmallCheckMark Proof of Employment and Income 

  • Four most recent payroll check stubs
  • Employment Verification form 
  • Current award letter / copies of checks: SSI, RSDI, VA, Soc. Sec., TANF
  • Workman's Compensation
  • Employer statement of earnings on letter head
  • Court orders/check for Child Support /Alimony
  • Unemployment award letter/check stubs
     
 

SmallCheckMark Verification sources of no income (all applicable) 

  • Food Stamp/TANF and Housing Assistance award letters
  • Statement from Homeless Shelter where patient resides and verifying unemployment.
  • Verification of Assistance form with notary seal and all of the following proofs from the person providing assistance:
    • Driver's license or DPS ID card
    • Utility bill
    • Proof of income
       
     
 
   

SmallCheckMark Proof of Patient Residency (minimum of two)

  • Utility, telephone and cable bills
  • Lease agreement, rent receipt, mortgage statement
  • Auto, Life, Homeowners/Renter's Insurance Documents
  • County, State/Federal agencies Correspondence
  • Retirement Plan Documents, Attorney Correspondence
  • Texas Department of Motor Vehicle Records
  • Statement from Homeless Shelter
     
 

SmallCheckMark Proof of Insurance (for all household members)

  • Front and back of Medical/Dental Insurance cards
     
 

SmallCheckMark Proof of Self Employment (No taxes withheld from income)

  • Self Employment Form (1 form each month)
  • Entire 1040 Tax Return Form with: Schedule C, 1099, Partnership Form 1065, Schedule K-1, Schedule F etc.
  • Business ledgers/Accountant s statement listing income and expenses for the last 12 months
  • 12 months of check stubs, receipts, or logs for income received: babysitting, contract/sub-contract work, landscaping, day labor work etc.
     
 

SmallCheckMark Acceptable sources to verify deductions
If desiring to claim deductions for child care, alimony or child support paid out:

  • Statement listing last four payments to provider
  • Last four canceled checks
  • Copy of divorce decree stating amount owed
  • Statement from Attorney General's office
  • Statement from ex-spouse itemizing payments
     
 

SmallCheckMark Assets, Debts & Liabilities 

  • Certificate or dividend statement
  • Car title / make, model and value
  • Individual Retirement Account
  • Proof of insurance policies
  • Property tax statement or deed/title
  • Oil, gas, mineral rights (bring statement)
  • Car loan agreement or statement
  • Unpaid medical bills
  • Lending institutions account #'s & available credit line
     
 


 

Step 2