Financial Counseling

Required Documents


To qualify for financial assistance with medical bills at the UT Health Northeast, it is the responsibility of the patient to provide the Financial Counseling Office with photocopies of the following documents. Please ensure that your name is on all information submitted. All information will be treated as confidential.

Income Received: (Bring all that apply)
  1. Social Security Check - actual copy or proof of direct deposit in bank account
  2. SSI Check (Disability) - actual copy or proof of direct deposit in bank account
  3. Employment (latest check stub showing year to date earnings - three month period)
  4. Pension / VA Check - actual copy or proof of direct deposit in bank account
  5. Worker’s Compensation Check or Unemployment Check
  6. AFDC Verification of monthly amount
  7. Food Stamps Verification of monthly amount
  8. Rental Property Income
  9. Oil / Gas Lease
  10. Dividends / Interest
  11. Child Support (Divorce decree or copy of check)
  12. Any other types of income not specified above
Additional Documents:
  1. Driver’s License (Valid Texas I.D. may be accepted in some cases.
  2. Bank Checking statements (on Bank Letterhead) with all pages covering last three months
  3. Savings Statements with all pages covering last three months
  4. Stocks / Bonds / CDs / IRAs / 401Ks / etc - Current Value documentation
  5. Income Tax Statement and/or IRS Tax Transcript - current, complete with 1099s & W2s **if self employed, Schedule C is required. To obtain an IRS Tax Transcript call: 1-800-829-1040
  6. Life Insurance Policy - Copy needs to have cash value
  7. Auto Liability Insurance Card - Must show all vehicles covered
  8. Property Tax Statement - all properties (business, home, etc)
  9. Rent Receipt with physical address on receipt (typed or written)
  10. Other, as requested
Verification of Application For:
  1. QMB/SLMB/Q1-1 at your designated Department of Health and Human Services
  2. Food Stamps
  3. SSI/Disability at your designated Social Security Administration Office
  4. County Indigent Health Care Program

NOTICE: Protected health information is subject to electronic disclosure.