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1 Avenue N

 •  Haskell, TX 79521

 •  (940) 864-2621

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Haskell Memorial Hospital

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Notice to the Public on Indigent Care

April 28, 2016

Logo for Texas Department of State Health Services

Haskell Memorial Hospital District will use the following application procedure in compliance with the Indigent Health Care and Treatment Act

  • All applicants must complete an application for assistance.  Supporting documentation must also be supplied upon request.
  • Haskell County residency must be established.
  • Income eligibility will be subject to current indigent income guidelines as noted in the CIHCP Program Handbook.
  • Ineligibility for other health programs (i.e. Medicaid, Texas Rehabilitation Commission, etc.) must be presented in writing.
  • Applicants will be notified of additional items needed to determine indigent status.  If required, information that is not provided within fourteen (14) days, the application will be denied.
  • A supplemental authorization to verify eligibility must be signed by the applicant.
  • On request of an applicant, A Hospital district employee shall assist an applicant in the completion of forms.  Each applicant will be informed of the availability of assistance.
  • The Hospital District shall provide a process for reviewing the application and allowing applicants to appeal a denial of assistance.  An appeals process shall accompany each denial.  Appeals may be offered to the Governing Body of the Hospital District at the next scheduled meeting of the Board of Directors following notification of intent to appeal.
  • The Hospital District shall maintain the records relating to each application for at least three (3) years after the date on which the application was submitted.

Applications may be obtained at Haskell Memorial Hospital, 1 North Avenue N, Haskell, Texas 79521.

Assistance with completing the application is available by appointment.  Please call 940-864-2621 for an appointment.

Haskell Memorial Hospital District will adhere to the policies and procedures set forth by the Board of Directors and the County Indigent Health Care Program Handbook published by the Texas Department of State Health Services.

Caution:  Presenting false information or securing medical benefits wrongfully may subject applicant to criminal and civil penalties.