MHAP Patient Form MHAP Patient FormBasic InformationAre you filling this form on behalf of an individual Yes NoSuffixFirst NameLast NameGender Male Female Do not wish to discloseDate of BirthPrimary Phone Home Mobile WorkPhone NoEmailAddressAddress Line 1Address Line 2CityStateZip CodeMarital StatusDemographicsRacePreferred PronounPrimary LanguageEmergency ContactRelationship to ContactFirst NameLast NamePrimary Phone Home Mobile WorkPhone NoEmailAddressAddress Line 1Address Line 2CityStateZip CodeMust live in Texas- Select an option -Lease agreementCurrent utility billMail postmarked (last 30 days)Upload Document Picture ID- Select an option -Driver’s licensePassportInsurance IDUpload Document Proof of U.S. Citizenship or Residency for your household members, if applicable- Select an option -Birth certificateLegal permanent Resident CardPassportUpload Document Proof of your household’s monthly income- Select an option -Pay StubBank statementsEmployer statement (Letter)Tax Returns (1040)Disability Insurance DocumentationSocial Security paymentsUpload Document Insurance Card (If insured)- Select an option -Medicare IDMedicaid IDCommercial insurance IDUpload Document Proof of your household size- Select an option -Birth certificatesMarriage certificatesFederal Tax returnsLegal guardianship papersPay stubsLease agreementOther verifiable sources of proof of household size will be consideredUpload Document Submit Form