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Harris Health System Economic Support Declaration Form

This form is used to declare economic support from a non-spouse individual for a client of Harris Health System. Completion of this form may be required under Texas Penal Code Sections 31.04 and 37.10. The person providing support must furnish their information and details of support provided.

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How do I fill this out?

Filling out this form requires providing personal information, details of support received, and a signature. Ensure all provided information is accurate and complete. Follow the outlined steps for each required section.

How to fill out the Harris Health System Economic Support Declaration Form?

1
Provide the name of the client.
2
Enter the name and relationship of the person providing support.
3
Specify the income sources of the support provider.
4
Indicate the type and frequency of support provided.
5
Sign and date the declaration form.

Who needs the Harris Health System Economic Support Declaration Form?

1
Individuals who receive economic support from someone other than their spouse.
2
Persons providing financial or other types of support to a client of Harris Health System.
3
Clients of Harris Health System detailing economic support for legal or medical reasons.
4
Caregivers needing to document financial support provided to clients.
5
Healthcare administrators managing client support declarations.

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1
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What are the instructions for submitting this form?

What are the important dates for this form in 2024 and 2025?

What is the purpose of this form?

Tell me about this form and its components and fields line-by-line.

What happens if I fail to submit this form?

How do I know when to use this form?

What are the instructions for submitting this form?

Submit the completed form to Harris Health System via mail, fax, or online submission. Mail: Harris Health System, P.O. Box 66769, Houston, TX 77266. Fax: (713) 634-1246. Online Submission: Please visit the Harris Health System Document Control Center at https://apps.hchd.local/sites/dcc for online form submission.

What are the important dates for this form in 2024 and 2025?

Form submission deadlines for 2024 and 2025 will be specified by Harris Health System upon issuance of the form.

What is the purpose of this form?

The purpose of this form is to document financial or other types of support provided to a client of Harris Health System by someone other than their spouse. This ensures that the support is officially recognized and legally compliant under relevant sections of the Texas Penal Code. The form helps to clarify the nature of the support provided and the responsibilities of the support provider.

Tell me about this form and its components and fields line-by-line.

This form includes sections to gather detailed information about the client and the support provider. Each field should be filled accurately to ensure completeness and compliance.

1. Client's Name: The full name of the client receiving support.
2. Support Provider's Name: The name of the individual providing economic support.
3. Relationship to Client: The nature of the relationship between the support provider and the client.
4. Income Sources: Details about the income sources of the support provider.
5. Support Period: The duration for which the support has been provided.
6. Type of Support: Whether the support includes lodging, food, money, or direct payment of expenses.
7. Signature: The support provider's signature confirming the information provided.
8. Print Name: The printed name of the support provider.
9. Phone Number: Contact number for verification purposes.
10. Date: The date when the form was signed.

What happens if I fail to submit this form?

Failing to submit this form can lead to legal and administrative consequences. It affects compliance with Harris Health System's requirements and Texas law.

Legal Implications: Non-compliance with Texas Penal Code Sections 31.04 and 37.10.
Medical Billing: Impact on the client's medical billing responsibilities.
Support Verification: Inability to verify the support provided to the client.

How do I know when to use this form?

Use this form when documenting economic support provided to a client by a non-spouse. It is necessary for legal, medical, and administrative purposes.

1. Client Support Verification: Confirming the details of economic support provided to clients.
2. Legal Documentation: Ensuring compliance with relevant sections of the Texas Penal Code.
3. Medical Billing: Providing necessary information for accurate medical billing.
4. Administrative Records: Maintaining proper records for Harris Health System.
5. Caregiver Accountability: Documenting support provided by caregivers to clients.

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What information is required for the Economic Support Declaration Form?

You need to provide the client's name, the support provider's details, the type and period of support, and signatures.

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