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1107 E. Marshall Ave Bldg #2. 1711 S. Henderson #400 602 N

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1107 E. Marshall Ave Bldg #2. 1711 S. Henderson #400 602 N
1107 E. Marshall Ave Bldg #2.
Longview, TX 75601
1711 S. Henderson #400
Kilgore, TX 75662
602 N. Titus St #130
Gilmer, TX 75644
903.758.2610
To qualify for Department State Health Service programs Title V, DSHS, Primary Health
Care, Breast and Cervical programs and Sliding Scale Assistance:
An appointment must be made to be screened for these program services and assistance. A
patient does not have to complete this process prior to seeing a physician. The following
information is required to complete the process:
(Bringing all information does not guarantee eligibility)
1. Identification for yourself, spouse and/or partner (whether married or living together), and all
of your minor child(ren) (one of the following)
A. Valid ID card
C. Valid TX Drivers License / Permanent Resident Card
B. Birth Certificate(s)
D. Passport / Voter ID card
2. Proof of Income (All of the following)(If spouse and/or partner’s income used he/she must
schedule an appointment to sign paperwork)
A. 4 Consecutive most recent pay stubs
D. Worker’s Compensation
B. Child Support
E. Unemployment
C. Social Security (Award Letter)
F. TANF benefits / Other Income
3. Proof of Address (Documents must be current with physical address)
A. Driver’s License
E. House Title
B. Utility Bill
F. Property Tax Statement
C. Rent/Lease Agreement
G. Bank Statement
D. Mortgage Statement
H. Letter from home owner/tenant responsible
4. Letter of Support and Identification of Supporter
The letter must be written by the person providing room and board and/or assistance to pay for
household bills and personal items. The letter must be signed, dated, and include a current
phone number where we can contact the supporter.
FOR MEDICAID APPOINMENTS CALL 903.758.2610 EXT. 4623 OR 4624
Mission: The mission of Wellness Pointe is to provide access to high quality medical, dental, and social
services across the patient lifecycle without regard to insurance status or ability to pay.
Rev. 4/2/13
1107 E. Marshall Ave Bldg #2.
Longview, TX 75601
1711 S. Henderson #400
Kilgore, TX 75662
602 N. Titus St #130
Gilmer, TX 75644
903.758.2610
Para todos los pacientes que quieren calificar para los programas de
Titulo V,Titulo X, Sliding Scale, Primary Health Care y Breast and Cervical:
Todos los paciente seran entrevistados por medio de una cita.
Para una aplicacion completa DEBE de traer los sigientes documentos:
(esto no garantiza que sera elegible)
Identificacion para usted y su pareja (esposo/ esposa).
A. Tarjeta de Indentificacion
B. Licensia de Manejo de valida
C. Acta de Nacimiento
1. Acata de nacimiento para todos sus hijos menores de edad o
dependes de su hogar.
2. Prueba de ingresos de todo el hogar.
A.
B.
C.
D.
E.
F.
G.
Los ultimos 4 talones de cheques ( los mas recientes).
Compensacion al trabajodor
Sostenimiento de ninos
Desempleo
Beneficios de TANF
Seguro Social
Comprovante de otros ingresos
3. Prueba de domicilio con fecha reciente.
A. Bill de servicios de casa ( agua, luz, telefono ect..)
B. Aseguranca de automobile
4. Carta con indentificaion- para todas las personas que no trabajan se
require una carta de sostenimiento. La persona que les ayuda con gastos
personales tendra que aser una carta con firma, numero telefonico y
numero de contacto.
Citas para Longview 903-758-2610.
Mision: La Mision de WellnessPointe es dar la major atencion medica, dental y servicios
sociales para todos los pacients con oh sin aseguranca medica y sin la abilidad de pago.
Mission: The mission of Wellness Pointe is to provide access to high quality medical, dental, and social
services across the patient lifecycle without regard to insurance status or ability to pay.
Rev. 4/2/13
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