Files Transferred to T: Drive
This site is intended for Travis County Residents who have submitted a MAP application and were asked for additional documents. Please upload required documents and click submit. You can find a complete list of the documents needed at www.centralhealth.net. Central Health will review the information submitted and will send you a letter or email, if you authorize us to do so, regarding any additional information or documents needed to complete your application. Call 512-978-8130 if you have any questions. If you have not submitted an application you may apply online at apply4map.net.
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This is not an application.
This site is intended for missing proof documents only.
Have you submitted a complete application in the last 30 days?
Yes
No
If you have not submitted a complete application go to apply4map.net to submit an application online or call 512-978-8130 to receive an application by mail.
What method did you use to apply for MAP?
Online at apply4map.net
Mail
Other
What date did you submit your application online or sent it by postal mail?
Today M-D-Y
First Name
* must provide value
Last Name
* must provide value
Date of Birth
* must provide value
M-D-Y
If you know your MAP ID#, enter here:
How many household members were included on your family's MAP Application?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Upload Photo Identification
Upload a picture ID. Any ID with a name and photo will be accepted.
2 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
3 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
4 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
5 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
6 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
7 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
8 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
9 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
10 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
11 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
12 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
13 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
14 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
15 Upload Photo Identification or Birth Certificate
Please upload a picture ID such as a DL, Passport, etc,. If you are unable to provide this, please use the link provided...
Address Document Must Be From the Last 30 Days. Accepted documents include, but are not limited to the following: Current Driver's License, Current Utility Bill, lease, Social Secuity Award Letter, any piece of mail postmarked in the last 30 days.
Use as many of the following income fields as you need to provide income proof documentation. If you need more, please use the additional fields at the bottom.
Upload all proof documents that provide income amounts from last 30 days.
Upload all proof documents that provide income amounts from last 30 days.
Upload all proof documents that provide income amounts from last 30 days.
Upload all proof documents that provide income amounts from last 30 days.
Were you asked to provide a Zero Income Statement or Income with No Tax Deductions Form?
Zero Income Statement
Income with No Tax Deductions Form
I, ______ ______ , certify that my household has received zero income in the last 30 days.
Name of person requested to fill out form
What is the total income you received in the last 30 days?
Are taxes withheld in your pay/income?
Yes
No
I, ______ have earned $______ in the last 30 days and no taxes were withheld.
Were you asked to submit an Applicant Responsibilities form to complete your MAP Application?
Yes
No
Please enter the full name of the client requested to sign Applicant Responsibilities
The signature on the following Applicant Responsibilities must be signed by this individual. La firma de las siguientes responsabilidades del solicitante deben ser firmadas por esta persona
IMPORTANT PLEASE READ: You must sign and initial the Applicant Responsibilities sections below for the application to be considered valid. Once you have signed the Applicant Responsibilities you may send your application to Central Health for processing by clicking "Submit". If you do not wish to submit an application do not click submit, simply close the window.
Download and review the Applicant Responsibilities in full. It is important you read the entire document and understand your responsibilities as a MAP enrollee.
By selecting the box on the right, you are acknowledging you have read and understand the Applicant Responsibilities.
* must provide value
SELECT HERE TO SIGNIFY APPLICANT RESPONSIBILITIES WAS REVIEWED
My authorization for my employer, the Social Security Administration, the Texas Health & Human Services Commission, the Texas Department of State Health Services, and the Texas Workforce Commission to release benefits, enrollment, claims, wage, and other records to Central Health; and
* must provide value
My authorization will be valid for a period of twelve months from the date I sign this Applicant Responsibilities form or until I revoke my authorization in a signed writing delivered to Central Health; and
* must provide value
My acknowledgement that I am responsible for ensuring that my mailing address, telephone number, and any cell phone number or email address I list beneath the next paragraph are accurate and are up to date (i.e. current) at all times during my Program enrollment; and
* must provide value
(Optional) I understand there are risks associated with sending unencrypted text messages and emails, and I am providing my consent to receive information from Central Health regarding scheduled appointments, my application status, renewals and changes to Program coverage and services.
Choose preferred communication method
You must enter a cellular phone number here to receive text notifications
Applicant Responsibilities Signature
* must provide value
You may also submit a completed Applicant Responsibilities here:
IMPORTANT PLEASE READ: As a new requirement for completion of your family's Central Health MAP Application, every household member over the age of 18 must sign the Applicant Responsibilities. Once you have signed the Applicant Responsibilities you may send your application to Central Health for processing by clicking "Submit". If you do not wish to submit an application do not click submit, please just close the browser window.
Download and review the Applicant Responsibilities in full. It is important you read the entire document and understand your responsibilities as a MAP enrollee.
By selecting the box on the right, you are acknowledging you have read and understand the Applicant Responsibilities.
* must provide value
SELECT HERE TO SIGNIFY APPLICANT RESPONSIBILITIES WAS REVIEWED
My authorization for my employer, the Social Security Administration, the Texas Health & Human Services Commission, the Texas Department of State Health Services, and the Texas Workforce Commission to release benefits, enrollment, claims, wage, and other records to Central Health; and
* must provide value
My authorization will be valid for a period of twelve months from the date I sign this Applicant Responsibilities form or until I revoke my authorization in a signed writing delivered to Central Health; and
* must provide value
My acknowledgement that I am responsible for ensuring that my mailing address, telephone number, and any cell phone number or email address I list beneath the next paragraph are accurate and are up to date (i.e. current) at all times during my Program enrollment; and
* must provide value
(Optional) I understand there are risks associated with sending unencrypted text messages and emails, and I am providing my consent to receive information from Central Health regarding scheduled appointments, my application status, renewals and changes to Program coverage and benefits via-
Choose preferred communication method
You must enter a cellular phone number here to receive text notifications
Applicant Responsibilities Signature
* must provide value
You may also submit a completed Applicant Responsibilities here:
Additional Document Upload
Additional Document Upload
Additional Document Upload
Additional Document Upload
M-D-Y H:M