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Terms of Service: Please keep in mind that communications over the internet are not guaranteed to be secure. Although it is unlikely, there is always a possibility that the information you provide can be intercepted and read by other parties. While we will never sell your information, Help America Corporation does not take responsibility for any third-party malicious attacks or any attempts to access your information. By selecting the 'I accept' box below, you acknowledge that you have understood, and accept the risk associated with transmitting personal data online. You agree to dismiss Help America Corporation from any suit, and agree to not hold Help America Corporation responsible for any theft, loss or attempt to access your personal information.
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Are you the Patient?
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What is your relation to the patient?
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  • Parent
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  • Relative
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Lets start with your citizenship status
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What is the Citizenship status for the Patient?
Answer this question about the patient to the best of your ability
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What is your sex?
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What is the sex of the patient?
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Was your hospital visit Pregnancy related?
This question is used to determine TP30/TP40 Medicaid Eligibility. We will not disclose this information with anyone. If you do not feel comfortable answering the question, please select 'I would rather not say' and move on.
We kindly ask for your cooperation, if now is not the right time - save this form for later. We want you to get better.
We kindly ask for your cooperation, if now is not the right time - save this form for later. We want you to get better.

We would love to speak with you. You may qualify for help with your doctors visits & the delivery at the hospital. Call us at (956) 365-1834

Was the patients hospital visit pregnancy related?
This question is used to determine TP30/TP40 Medicaid Eligibility. We will not disclose this information with anyone. If you do not feel comfortable answering the question, please select 'N/A' and move on.
We kindly ask for your cooperation, if now is not the right time - save this form for later. We want you to get better.
We kindly ask for your cooperation, if now is not the right time - save this form for later. We want you to get better.

Depending on the household income, the patient may qualify for help with their Doctors visits, labor and the delivery at the hospital. Have the patient call us at (956) 365-1834 . All Services are free of charge!

Select your Marital status
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What is the patients marital status?
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Do you have any minor children in your household?

This will help determine if you are potentially eligible for Medicaid assistance
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  • 0 (I have no minors )
  • 1 Minor Child
  • 2 Minor Children
  • 3 Minor Children
  • 4 Minor Children
  • 5 Minor Children
  • 6 Minor Children
  • 7 Minor Children
  • 9 Minor Children
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Field is required!
Are your minor children US Born?
This will help determine if are you are potentially eligible for 1205 Medicaid
Please make a selection
Please make a selection

Does the patient have full custody of minor children?

This will help determine if they are potentially eligible for Medicaid assistance
  • - select a option -
  • 0 (I have no minors in my custody)
  • 1 Minor Child
  • 2 Minor Children
  • 3 Minor Children
  • 4 Minor Children
  • 5 Minor Children
  • 6 Minor Children
  • 7 Minor Children
  • 8 Minor Children
  • 9 Minor Children
- select a option -
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Field is required!
Are the patients Children US Born?
This will help determine if the patient is potentially eligible for 1205 Medicaid
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Please make a selection

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Employment Status
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Have you received any income in the last 3 months?
This includes any government assistance like SSI, RSDI, TANF, Child Support or Unemployment
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About how much money are you expected to make this month from your Work?
Please make an estimate. You can change your answer by speaking with a HELP AMERICA Representative at any time.
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Please use the slider to make a guess

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What is the patients employment status?
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Has the patient received any income in the last 3 months?
This includes any government assistance like SSI, RSDI, TANF, Child Support or Unemployment
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Field is required!
About how much money is the patient expected to make this month from his or her Job/Work?
Please make an estimate. You can change your answer by speaking with a HELP AMERICA Representative at any time.
Please use the slider to make a guess
Please use the slider to make a guess

Are you receiving any Government Assistance or Benefits?

We will not need the amounts at this time
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Field is required!

Is the patient receiving any Government Assistance or Benefits?

If you are unsure, select None of the Above
We will ask for these amounts at a later time
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Set up an appointment today!

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If you or someone you know is looking for help with an unpaid hospital bill please fill out the information below and explain your situation in the comments.

Contact Information

Fill out the information below and a Help America Representative will get back to you if you might qualify.
Your First Name
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Your Last Name
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Date of Birth
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Please enter the patients date of birth
Your Phone Number
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Your E-mail Address
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Welcome!

Take a minute to answer these questions, you may qualify for assistance with a hospital bill

ALL PROGRAMS ARE FREE OF CHARGE

Select the 'Start' button to begin!