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Notice
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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You need to read and accept to our terms of service!
You need to read and accept to our terms of service!
Are you the Patient?
Yes I am the patient
No, I am not the patient
Please make a selection
Please make a selection
What is your relation to the patient?
- select a option -
Parent
Guardian
Friend
Relative
None of the above
- select a option -
[{"field":"{PatientQ}","logic":"equal","value":"Patient_No","and_method":"","field_and":"","logic_and":"","value_and":""}]
Error fillt his thing out
Error
Lets start with your citizenship status
select one of the following options
US Citizen
Resident
Undocumented
I would rather not say
[{"field":"{PatientQ}","logic":"equal","value":"Patient_Yes","and_method":"or","field_and":"{Patient_Question2}","logic_and":"equal","value_and":"Relationship_Guardian"},{"field":"{Patient_Question2}","logic":"equal","value":"Relationship_Parent","and_method":"","field_and":"","logic_and":"","value_and":""}]
Field is required!
Field is required!
What is the Citizenship status for the Patient?
Answer this question about the patient to the best of your ability
US Citizen
Resident
Undocumented
I am not sure
[{"field":"{Patient_Question2}","logic":"equal","value":"Relationship_Friend","and_method":"or","field_and":"{Patient_Question2}","logic_and":"equal","value_and":"Relationship_Relative"}]
Field is required!
Field is required!
What is your sex?
select one of the following options
Male
Female
I would rather not say
[{"field":"{citizenship_status}","logic":"equal","value":"citizen","and_method":"or","field_and":"{citizenship_status}","logic_and":"equal","value_and":"resident"},{"field":"{citizenship_status}","logic":"equal","value":"undocumented","and_method":"or","field_and":"{citizenship_status}","logic_and":"equal","value_and":"noanswer"}]
Field is required!
Field is required!
What is the sex of the patient?
select one of the following options
Male
Female
I would rather not say
[{"field":"{citizenship_status2}","logic":"equal","value":"Citizen2","and_method":"or","field_and":"{citizenship_status2}","logic_and":"equal","value_and":"Resident2"},{"field":"{citizenship_status2}","logic":"equal","value":"Undocumented2","and_method":"or","field_and":"{citizenship_status2}","logic_and":"equal","value_and":"noanswer2"}]
Field is required!
Field is required!
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.
Yes
No
I would rather not say
[{"field":"{Status}","logic":"equal","value":"Female","and_method":"or","field_and":"{Status}","logic_and":"equal","value_and":"None"}]
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
[{"field":"{Pregnancy}","logic":"equal","value":"Pregnancy_Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
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.
Yes
No
N/A
[{"field":"{Status_2}","logic":"equal","value":"Female_2","and_method":"or","field_and":"{Status_2}","logic_and":"equal","value_and":"None_2"}]
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!
[{"field":"{Pregnancy2}","logic":"equal","value":"Pregnancy2_Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
Select your Marital status
Single
Married
Divorced
Widowed
[{"field":"{Status}","logic":"equal","value":"Male","and_method":"or","field_and":"{Status}","logic_and":"equal","value_and":"Female"},{"field":"{Status}","logic":"equal","value":"None","and_method":"","field_and":"","logic_and":"","value_and":""}]
Field is required!
Field is required!
What is the patients marital status?
Single
Married
Divorced
Widowed
[{"field":"{Status_2}","logic":"equal","value":"Male_2","and_method":"or","field_and":"{Status_2}","logic_and":"equal","value_and":"Female_2"},{"field":"{Status_2}","logic":"equal","value":"None_2","and_method":"","field_and":"","logic_and":"","value_and":""}]
Field is required!
Field is required!
Do you have any minor children in your household?
This will help determine if you are potentially eligible for Medicaid assistance
[{"field":"{MaritalStatus}","logic":"equal","value":"Single","and_method":"or","field_and":"{MaritalStatus}","logic_and":"equal","value_and":"Married"},{"field":"{MaritalStatus}","logic":"equal","value":"Divorced","and_method":"or","field_and":"{MaritalStatus}","logic_and":"equal","value_and":"Widowed"}]
- select a option -
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
- select a option -
[{"field":"{MaritalStatus}","logic":"equal","value":"Single","and_method":"or","field_and":"{MaritalStatus}","logic_and":"equal","value_and":"Married"},{"field":"{MaritalStatus}","logic":"equal","value":"Widowed","and_method":"or","field_and":"{MaritalStatus}","logic_and":"equal","value_and":"Divorced"}]
Field is required!
Field is required!
Are your minor children US Born?
This will help determine if are you are potentially eligible for 1205 Medicaid
Yes
No
[{"field":"{US_Minor_Question}","logic":"equal","value":"Minors_One","and_method":"or","field_and":"{US_Minor_Question}","logic_and":"equal","value_and":"Minors_Two"},{"field":"{US_Minor_Question}","logic":"equal","value":"Minors_Three","and_method":"or","field_and":"{US_Minor_Question}","logic_and":"equal","value_and":"Minors_Four"},{"field":"{US_Minor_Question}","logic":"equal","value":"Minors_Five","and_method":"or","field_and":"{US_Minor_Question}","logic_and":"equal","value_and":"Minors_Six"}]
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
[{"field":"{MaritalStatus2}","logic":"equal","value":"Single2","and_method":"or","field_and":"{MaritalStatus2}","logic_and":"equal","value_and":"Married2"},{"field":"{MaritalStatus2}","logic":"equal","value":"Divorced2","and_method":"or","field_and":"{MaritalStatus2}","logic_and":"equal","value_and":"Widowed2"}]
- 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 -
[{"field":"{MaritalStatus2}","logic":"equal","value":"Single2","and_method":"or","field_and":"{MaritalStatus2}","logic_and":"equal","value_and":"Married2"},{"field":"{MaritalStatus2}","logic":"equal","value":"Divorced2","and_method":"or","field_and":"{MaritalStatus2}","logic_and":"equal","value_and":"Widowed2"}]
Field is required!
Field is required!
Are the patients Children US Born?
This will help determine if the patient is potentially eligible for 1205 Medicaid
Yes
No
[{"field":"{US_Minor_Question2}","logic":"equal","value":"Minors_One","and_method":"or","field_and":"{US_Minor_Question2}","logic_and":"equal","value_and":"Minors_Two"},{"field":"{US_Minor_Question2}","logic":"equal","value":"Minors_Three","and_method":"or","field_and":"{US_Minor_Question2}","logic_and":"equal","value_and":"Minors_Four"},{"field":"{US_Minor_Question2}","logic":"equal","value":"Minors_Five","and_method":"or","field_and":"{US_Minor_Question2}","logic_and":"equal","value_and":"Minors_Six"}]
Please make a selection
Please make a selection
You are almost finished!
[{"field":"{US_Minor_Question}","logic":"equal","value":"Minors_None","and_method":"or","field_and":"{US_Child}","logic_and":"equal","value_and":"Minors_No"},{"field":"{US_Child}","logic":"equal","value":"Minors_Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
Employment Status
Please make a selection
Employed
Unemployed
Self-Employed
[{"field":"{PatientQ}","logic":"equal","value":"Patient_Yes","and_method":"or","field_and":"{US_Minor_Question}","logic_and":"equal","value_and":"Minors_None"},{"field":"{US_Child}","logic":"equal","value":"Minors_No","and_method":"or","field_and":"{US_Child}","logic_and":"equal","value_and":"Minors_Yes"}]
Field is required!
Field is required!
Have you received any income in the last 3 months?
This includes any government assistance like SSI, RSDI, TANF, Child Support or Unemployment
Yes
No
[{"field":"{Employment_Status}","logic":"equal","value":"Employment_Unemployed","and_method":"","field_and":"","logic_and":"equal","value_and":""}]
Field is required!
Field is required!
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.
[{"field":"{Employment_Status}","logic":"equal","value":"Employment_Employed","and_method":"or","field_and":"{Employment_Status}","logic_and":"equal","value_and":"Employment_Self"}]
Please use the slider to make a guess
Please use the slider to make a guess
You are almost finished!
[{"field":"{US_Minor_Question2}","logic":"equal","value":"Minors_None2","and_method":"or","field_and":"{US_Child2}","logic_and":"equal","value_and":"Minors_Yes2"},{"field":"{US_Child2}","logic":"equal","value":"Minors_No2","and_method":"","field_and":"","logic_and":"","value_and":""}]
What is the patients employment status?
Please make a selection
Employed
Unemployed
Self-Employed
[{"field":"{Patient_Question2}","logic":"equal","value":"Relationship_Friend","and_method":"","field_and":"","logic_and":"","value_and":""}]
Field is required!
Field is required!
Has the patient received any income in the last 3 months?
This includes any government assistance like SSI, RSDI, TANF, Child Support or Unemployment
Yes
No
[{"field":"{Employment_Status2}","logic":"equal","value":"Employment_Unemployed2","and_method":"","field_and":"","logic_and":"","value_and":""}]
Field is required!
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.
[{"field":"{Employment_Status2}","logic":"equal","value":"Employment_Employed2","and_method":"or","field_and":"{Employment_Status2}","logic_and":"equal","value_and":"Employment_Self2"}]
Please use the slider to make a guess
Please use the slider to make a guess
Are you receiving any Government Assistance or Benefits?
[{"field":"{Employment_Status}","logic":"equal","value":"Employment_Employed","and_method":"or","field_and":"{Employment_Status}","logic_and":"equal","value_and":"Employment_Unemployed"},{"field":"{Employment_Status}","logic":"equal","value":"Employment_Self","and_method":"","field_and":"","logic_and":"","value_and":""}]
We will not need the amounts at this time
Food Stamps
Child Support
SSI Disability
RSDI
Workers Compensation
Unemployment
None of the above
[{"field":"{Benefits}","logic":"equal","value":"Nobenefits","and_method":"","field_and":"","logic_and":"","value_and":""}]
[{"field":"{Employment_Status}","logic":"equal","value":"Employment_Employed","and_method":"or","field_and":"{Employment_Status}","logic_and":"equal","value_and":"Employment_Unemployed"},{"field":"{Employment_Status}","logic":"equal","value":"Employment_Self","and_method":"","field_and":"","logic_and":"","value_and":""}]
Field is required!
Field is required!
Is the patient receiving any Government Assistance or Benefits?
If you are unsure, select None of the Above
[{"field":"{Employment_Status2}","logic":"equal","value":"Employment_Employed2","and_method":"or","field_and":"{Employment_Status2}","logic_and":"equal","value_and":"Employment_Unemployed2"},{"field":"{Employment_Status2}","logic":"equal","value":"Employment_Self2","and_method":"","field_and":"","logic_and":"","value_and":""}]
We will ask for these amounts at a later time
Food Stamps
Child Support
SSI Disability
RSDI
Workers Compensation
Unemployment
None of the above
[{"field":"{PatientQ}","logic":"equal","value":"Patient_Friend","and_method":"or","field_and":"{Employment_Status2}","logic_and":"equal","value_and":"Employment_Employed2"},{"field":"{Employment_Status2}","logic":"equal","value":"Employment_Unemployed2","and_method":"or","field_and":"{Employment_Status2}","logic_and":"equal","value_and":"Employment_Self2"}]
Field is required!
Field is required!
Set up an appointment today!
[{"field":"{Patient_Question2}","logic":"equal","value":"Relationship_None","and_method":"","field_and":"","logic_and":"","value_and":""}]
Title
[{"field":"{PatientQ}","logic":"equal","value":"Patient_Yes","and_method":"or","field_and":"{Patient_Question2}","logic_and":"equal","value_and":"Relationship_Parent"},{"field":"{Patient_Question2}","logic":"equal","value":"Relationship_Friend","and_method":"or","field_and":"{Patient_Question2}","logic_and":"equal","value_and":"Relationship_Relative"},{"field":"{Patient_Question2}","logic":"equal","value":"Relationship_Guardian","and_method":"","field_and":"","logic_and":"","value_and":""}]
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.
[{"field":"{Patient_Question2}","logic":"equal","value":"Relationship_None","and_method":"","field_and":"","logic_and":"","value_and":""}]
Contact Information
Fill out the information below and a Help America Representative will get back to you if you might qualify.
Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Date of Birth
Select a date
Field is required!
Please enter the patients date of birth
Your Phone Number
Invalid phonenumber!
Invalid phonenumber!
Your E-mail Address
Field is required!
Field is required!
Would you like to receive text messages if you or the patient qualifies for assistance?
Yes, send me text messages about the application
Field is required!
Field is required!
Have any further questions or comments?
We are here to help! Provide any additional details such the best time to call or text you.
Ask us any questions...
Field is required!
Field is required!
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