forms

Eligibility Application

For eligibility interviews, please print, complete and bring the eligibility application to your eligibility interview.

Eligibility Application

Wage Verification Letter

A completed wage verification letter can be used in place of presenting a month's worth of recent paycheck stubs.

Wage Verification Letter

Statement of Support

A completed statement of support can be used in place of presenting a month's worth of recent paycheck stubs, if you are being financially supported by someone besides yourself or your spouse.

Statement of Support

Medical Records Release

For a copy of your medical records, please print, complete and bring or mail the medical records release form to the Clinic.

Medical Records Release Form

Dental Records Release Form

Notice of Privacy Practice and Rights & Responsibilities

Please review these documents to know the company’s privacy practice and rights & responsibilities

Notice of Privacy Rights

San José Clinic (Midtown) - 2615 Fannin St, Houston, TX 77002 - Tel: (713) 228-9411 - Fax: (713) 228-6371

San José Clinic (Fort Bend) - 1615 Avenue E, Rosenberg, TX 77471 - Tel: (832) 945-6711

We are a 501(c)(3), a United Way agency, and a ministry of the Archdiocese of Galveston-Houston and Texas Medical Center Institution.

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