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ARE YOU A NEW PEDIATRICS PATIENT TO SHF?
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NEW PEDIATRICS PATIENT
ESTABLISHED SHF PEDIATRICS PATIENT
SELECT THE SHF SERVICES YOU CURRENTLY ACCESS FOR PEDIATRICS
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MEDICAL
DENTAL
SHF REGISTRATION UPDATE ONLY
DATE OF REGISTRATION UPDATE
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SELECT SHF LOCATION (UPD)
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Greenspoint Health Center - 255 Northpoint, Ste. 200, Houston, TX 77060
Sugarland Health Center - 10320 Dairy Ashford, Ste 100 Sugarland TX 77478
CHILD'S DOB (UPD)
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CHILD LAST NAME (UPD)
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CHILD FIRST NAME (UPD)
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MIDDLE (UPD)
MOTHER'S NAME (LAST, FIRST) (UPD)
MOTHER'S OCCUPATION (UPD)
FATHER'S NAME (LAST, FIRST) (UPD)
FATHER'S OCCUPATION (UPD)
ADDRESS (UPD)
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CITY (UPD)
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COUNTY (UPD)
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Harris
Fort Bend
Montgomery
Galveston
Austin
Chambers
Colorado
Huntsville
Liberty
San Jacinto
Walker
Waller
Wharton
Other
STATE (UPD)
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
ZIP CODE (UPD)
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PRIMARY PHONE (UPD)
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ALTERNATE PHONE (UPD)
PARENT EMAIL (UPD)
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PARENT HOUSING STATUS (UPD)
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Own Home / Mortgage
Rental Housing
Rented Room
Participant-Owned Housing
Homeless - Living in Shelter
Homeless - No Shelter
Homeless - Transitional Housing
Homeless - Staying with Others
Hospital
Jail/Prison
Assisted Living / Nursing Home
Substance Abuse Treatment Facility
Psychiatric/Mental Health Facility
Refused To Answer
DID PARENT FILE TAXES LAST YEAR?
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YES
NO
MODIFIED ADJUSTED GROSS INCOME WORKSHEET (INCOME TAX FILERS)
DOLLAR ($$)
(+) Adjusted Gross Income - Form 1040EZ - Line 4
DOLLAR ($$)
(+) Adjusted Gross Income - Form 1040A - Line 21
DOLLAR ($$)
(+) Adjusted Gross Income - Form 1040 - Line 37
DOLLAR ($$)
(+) Non-Taxable SS Benefits - Form 1040 - Line 20a-20b
DOLLAR ($$)
(+) Non-Taxable SS Benefits - Form 1040A - Line 14a-14b
DOLLAR ($$)
(+) Tax-exempt Interest - Form 1040 - Line 8b
DOLLAR ($$)
(+) Foreign Earned Income - Form 2555
DOLLAR ($$)
(-) Income - Scholarships, Grants, Awards
DOLLAR ($$)
(-) Certain Income Native America
DOLLAR ($$)
(-) Lump sum received for 1 month
DOLLAR ($$)
Modified Adjusted Gross Income (MAGI) =
DOLLAR ($$)
MODIFIED ADJUSTED GROSS INCOME WORKSHEET (NO TAX RETURNS FILED)
DOLLAR ($$)
(+) Wages, Salaries, Tips, etc
DOLLAR ($$)
(+) Taxable Interest
DOLLAR ($$)
(+) Tax Exempt Interest
DOLLAR ($$)
(+) IRA Distributions - Taxable Amount
DOLLAR ($$)
(+) Pensions & Annuities
DOLLAR ($$)
(+) Retirement Income from SSA
DOLLAR ($$)
(+) Disability Income SSDI
DOLLAR ($$)
(+) Non-taxable Social Security Benefits
DOLLAR ($$)
(+) Business Income (or loss)
DOLLAR ($$)
(+) Farm Income (or loss)
DOLLAR ($$)
(+) Capital Gain (or loss)
DOLLAR ($$)
(+) Other Gains (or losses)
DOLLAR ($$)
(+) Unemployment Income
DOLLAR ($$)
(+) Ordinary Dividends
DOLLAR ($$)
(+) Alimony or other Spousal Support Received
DOLLAR ($$)
(+) Rental Real Estate, S Corporations
DOLLAR ($$)
(+) Taxable Refunds / Credits - State Income Tax
DOLLAR ($$)
(+) Other Income (Jury Duty Pay, Gambling Winnings)
DOLLAR ($$)
(+) Foreign Earned Income & Housing Living Abroad
DOLLAR ($$)
(-) Deductible Part of Self Employment Tax
DOLLAR ($$)
(-) Self Employed SEP, Simple Gains
DOLLAR ($$)
(-) Self-Employment Health Insurance Deductions
DOLLAR ($$)
(-) Student Loan Interest Deduction
DOLLAR ($$)
(-) Tuition and Fees
DOLLAR ($$)
(-) Scholarships, Awards, Fellowships Grants
DOLLAR ($$)
(-) Educator Expenses
DOLLAR ($$)
(-) IRA Deduction
DOLLAR ($$)
(-) Moving Expenses
DOLLAR ($$)
(-) Penalty on Early Withdrawal of Savings
DOLLAR ($$)
(-) Health Savings Account
DOLLAR ($$)
(-) Alimony Paid
DOLLAR ($$)
(-) Domestic Production Activities
DOLLAR ($$)
(-) Business Expenses
DOLLAR ($$)
(-) Certain American Indian Income
DOLLAR ($$)
(-) Amount Received As a Lump Sum (not monthly)
DOLLAR ($$)
MODIFIED ADJUSTED GROSS INCOME
DOLLAR ($$)
MODIFIED ADJUSTED GROSS INCOME MONTHLY (UPD)
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PERSONS IN HOUSEHOLD (UPD)
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1
2
3
4
5
6
7
8
9
10+
EMERGENCY CONTACT UPDATE
DO YOU NEED TO UPDATE THE EMERGENCY CONTACT PERSON
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YES
NO
EMERGENCY NAME (UPD)
EMERGENCY CONTACT RELATIONSHIP (UPD)
Spouse
Partner
Parent
Grandparent
Sibling (Brother/Sister)
Child (18 years or older)
Aunt/Uncle
Cousin/Relative
Friend
EMERGENCY CONTACT PHONE (UPD)
EMERGENCY CONTACT ADDRESS (UPD)
EMERGENCY CONTACT EMAIL (UPD)
HAVE YOU INFORMED THIS PERSON YOU ARE RECEIVING SERVICES FROM SHF? (UPD)
Yes
No
UPDATED PROOF OF RESIDENCE AND INCOME
PROOF OF INCOME (UPD)
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PROOF OF RESIDENCE (UPD)
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INTEROFFICE USE ONLY
SHF REPRESENTATIVE COMPLETING UPDATE:
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COMPLETED BY PATIENT
ASHLEY JOHNSON
ADONIS MAY
ANGELA PRINCE
KRISTINA SADLER
AJAI MUWWAIKIL
CANDICE WALLACE
ASHLEY GANT