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(Haga clic aquí para completar la solicitud en línea)
(xin nh?n vào ch? này d? di?n m?u don qua m?ng )
 

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:
 

Income and asset information is not required from parents of an adult child who is applying for JPS Connection coverage.
 

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 online application.
 

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.