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Documentation Requirements for JPS Connection Indigent Healthcare Program
** Please bring back items from following categories **
Please note that additional information may be requested at the time of your interview.
 Proof of Patient Identification
- 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
Social Security Number for all applicable household members.
Provide (all applicable)
- Most recent checking and savings account statements
- Entire 1040 Tax Return Form with: Schedule C, Partnership tax form 1065, Schedule K-1, Schedule F, W2 etc.
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
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
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Proof of Patient Residency (minimum of two)
- Utility, telephone and cable bills
- Lease agreement, rent receipt, mortgage statement
- Auto, Life, Homeowners/Renter's Insurance
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