(xin nhấn vào chỗ này để điền mẫu đơn qua mạng )
Dear Applicant:
Welcome to JPS Health Network. Attached you will find the application for our JPS Connection Program offered through the JPS Health Network. Completion of this application will enable us to consider you for discounted medical services at JPS Health Network facilities.
To become eligible for our JPS Connection Program, please complete this application and return it to us along with supporting documentation at your earliest opportunity so we can process your application. Supporting documentation includes:
- Identification: Drivers license, Texas Identification Card or birth certificate for each member of the household (as applicable), and copies of social security cards.
- Residence: Proof of residence in Tarrant County such as copy of a lease or utility bills
- Income and Assets: Four recent check stubs, and recent bank statements, tax returns, award letters.
We respect your privacy and want to assure you that the information you include with your application will be treated as confidential information and used only for eligibility verification purposes.
Please return the completed application and supporting documents to our eligibility center by mail or fax or CLICK HERE TO FILL OUT OUR ON-LINE APPLICATION FORM
If you have more than four members in your household, please print a Word or PDF application from the links below and fax or mail your application to the JPS Enrollment Center.
JPS Eligibility Center
1325 South Main Street
Fort Worth, Texas 76104
Fax: (817) 927-3834
If you need assistance completing this application, have any questions, or would like to schedule a financial screening appointment, please call the JPS Eligibility Center at 817-927-1001 or the JPS Call Center at 817-222-2377.
| Forms provided in this packet. Please note – Forms marked with an asterisk (*) are required. |
Documents for Download |
| Proof List - This document provides general information listing examples of acceptable proofs you can provide from each of the required categories. |  Microsoft Word Adobe PDF |
| Application * - The application must be completed and signed. | Microsoft Word Adobe PDF |
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Verification of Assistance Form - This form is only required if you are receiving or have recently received assistance from friends or family. The person you are living with and/or friends & family providing you with assistance must complete this form. In addition to completing this form the person providing assistance must provide a copy of their driver’s license and utility bill. |
Microsoft Word Adobe PDF |
Please note - Anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth in the completion of the application process is committing a crime which can be punished under Federal law, State law, or both. If at any time false information is discovered penalties will include, but are not limited to, loss of my membership benefits and the inability to reapply for the JPS Connection Indigent Healthcare Program for no less than a period of ninety (90) days.